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APPLICATION FOR SANITATION PERMIT Permit No. ._/ __ a__G (Complete in Duplicate) w_ � •- pate*Issued --------------- Applilion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A D LOCATION___�___�2__.___G__3_c -- ----tv ------ -------- ---------------------------------------------------------------------------------- : Owner's Name-----/ "1-�7--�(r. _/L.1 r6 �� Phone Address --•----------•-------------------------------------------------------------------------------------------------------------------------------------------•--------------- Contractor's Name-----------------------•----- ------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence artment House []',Commercial E] Trailer Court E] Mote ❑ O er ❑ Number of living units: /� unity _____ ber of bedrooms __ ___ Number of baths/------ Lot size _ _______ ____ __ f € Water Supply: Public system system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand E],-.Gravel ❑ Sandy Loam ❑ C y Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) f Septic Distance from nearest wel#.____ ��_Distance-from fo�ndat�io _ .I Mate al____ "___. _______ ________________ p p. ra No. of compartments-- -- -- - Siz` _ -4f� -__- -_�i!_r .uid depth_--- ----------------Capac�ty__�- -_U.d_� hp.N -� 'f�- f �- � r s.. is osal' I' Distance from nearest well_��-__.Distance from foundation__L ___________Distance to nearest lot li�________________ d .: Number of lines_-'_t------- --------------------Length of each line-------elo- --------------Width of trench---2- --------------------_" ' Type of filter material__lu"r _-_____Depth of filter material______.�f1------Total length______ _Q__ ----------------------- Seepage _Seepage Pit: Distance to nearest well---------------------- from foundation___------___-_.-___.Distance to nearest lot line----------------- Number ____ ______-Number of pits----------------------Lining material---------------_-------Size: Diameter-----------------------Depth__----_---------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------_-----Lining material_-________..___._____________________ ❑ Size: Diameter---------------------------- ----------Depth---------------------------------------------------.Liquid Capacity----------------------------gals. ( , Privy: Distance from nearest well.-----------------------------------------------Distance from nearest building_____________-___________-_-_---_---.__-_. ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)----------------------------------------------------------•------------------------------------- '-----------------------------•------------------------ t --------------------------------------------------•--------'---.-------.•----.-_--- ------------------------------------------------------------------------•-------:--------------------------------------------------------------------------------------------------------------------------------------------- - - ----------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County h ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Signed)------wla4��,_-_�Ilit ,4--- --------------------- -------------------------------------------------(Owner and/or Contractor) "' By:--------------------------------------------------------------------------------------- ---(Title)------------------------------ ---------------------------------------- --------------------------------- (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- - ---- - ----- ---------- -- -----------•-'-------------------------- DATE------------------------- REVIEWEDBY-------------------------------------------------- - --------------------------------------------------------- DATE---------•--•-------6....... .... --------------- EBUILDING PERMIT ISSUED--------------------------- -------------------------------------------------------------------- DATE----------------I------------------------------------------ Altera, 'gps and/or recommendations---------------------------------------------- ----------------------------------�-----------------"-----•-"-------- ---------------------------- --- ri ------- ---------------•--- --------- -- -••---- - ........:A- ---*-f - ----- ----------------------- ----------------- ----------------------------------------------------------------------- -------- ---------------------------------------- ---------------------- ------- ------------------------------------------------------------------------- -------------- FINAL ------------ --- -------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY: r - Date .------- - ----- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CO. 4