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APPLICATION FOR SANITATION PERMIT -. (Complete in Duplicate) r Permit No.--f-1-2� Date Issued 1Q/>/ Application 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 o. 549. JOB ADDRESS AND LO ATIO---_--- -- 'I a ------------------------------------------------ Owner's Name------------ -- ------Phone �; Address----------- ------------ ---_---------------- — _ ¢-T�,� Contractor's Name-------------------------tI----- —-------" 3 `` -----r--------------- ----------------------------------------- Phone--G_R_� 31i_4_ .- s Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E] Number of living units: -1----- Number of bedrooms _2Number of baths -)---- Lot size --------------------------__-__--_ Water Supply: Public system 2 -Community system ❑ Private ❑ Depth to Water Table #C7_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p Clay [❑ Adobe 8/Fi`ardpan ❑ Previous Application Made: Yes ❑ No [P— New Construction: Yes RT"'No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 11 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septiq Tank: Distance from nearest well----------------- Distance from foundat[or�-i__- --------------- Material -----------_-__.___.-------_-----___--.--------. No. of compartments -------------------------- Sizes_,------------------------ --Liquid depth -------------- ----------- Capacity ----------------------- Disposal field: Distance from nearest weft ----------------- Distance from foundation --------------------Distance to nearest lot line, ---------------- ,A* VNumber of lines------------------------------ ---- Length of each line----------------- 4 --------- .Width of trench ----------------------------------- �f Type of filter material ------------------------- Depth of filter material -------------- Total length ------------------------------------ Seepage Pit: Distance to nearest well_ --_Y--Distance rom foundation__.Q----------- Disa`c e to nearest lot line -__-----~_--_.__ Number of pits-.-./ --------------- Lining material-__ :–----- Size: Diameter....?_ .----_.____Depth-._._2-J'--_----.-____--.- Cesspool: Distance from nearest well ----------------- Distance from foundation --- .--------------- .Lining material ---.--.__-----------__._-_____-----. ❑ Size: Diameter -------------------------------------- Depth ------------------------------ ------- -------------Liquid Capacity ---------------------------- gals. Privy: Distance from nearest well ------- ___------_----- ❑ Distance to nearest lot line____________________ Remodeling and/or repairing (describe) - --------------------- J A O -------------- ------------ --Distance from nearest building ------------------------------------------ ------------------------------------------------------------------------------------------------ --------------------- __1D d' R -------------------------------------------------------------------------------------------------------------------------A ------------------------------------------------------------------------------------- ---------------------------------- -----------------••------------------------------------------------------------------------------------------------------ ------------- ----- ---------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (5i ned __.. g )-------- ='~------------------------------------------------------------------------------------ (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 r APPLICATION ACCEPTED BY..--__�(AJ-"_--.__k �.-_______________` �Q -------------------- DATE ------- REVIEWEDBY ------------------------------------------- ---------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED -------------------------------------------------------------- --------------------------------• DATE Alterations and/or recommendations, ------------------------------------------------- -----------------•------------------------------:------------------------------------------------------------------------------------------------------------------------------------- ---------------------•--------------- y�7 f j FINAL INSPECTION BY:.-_�',�..i�c --------------------- --------------------- Date----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES ---9--2M , Revisea 1.57 F.P.CO.