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APPLICATION FOR SANITATION PERMIT Permit No. J��_,.. ' (Complete in Duplicate) s Date Issued /c__�:'`...__.7_ 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 70, ' ante'No. 549. ' JOB ADDRESS A L ATIV --- Owner's _ - �: o� - Owner's Name : - ----- ----- --------------------------- =' - - ------------=----------------------- Phone------------------------------------ Address----------------f' ----- -----�- ( =j ' --------------•---- ------ ----------------------------------------------- Contractor's --------- -------Contractor`s Name ----- -----------------•--- Phone. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer. Court ❑ Motel ❑ Other ❑ Number of living units: __J---- Number of bedrooms _-3..-Number.of baths ____ Lot size__ _-- �._____.._.__..-__,_.________ Water Supply: Public system 2--l'Commuriity system ❑ Private ❑' Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay E] Adobe[Hardpan ❑ Previous Application Made: Yes ❑ No [+ New Construction: Yes Ee No ❑ RHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or'cesspool permitted if public sewer is available withi�00.feet.)1i a Septic Tank: Distance from nearest well------------ ---Distance from fou`ndation---------------------Material--------------------------.-_.--_.-__.__________- � No. of cbm arfinents_______y_______`___._'__Size___--_-_____-___ ----------------------------------cLigiid depth--------------------------Capacity------------•---------- QistDispo�,Rie anc e from nearest-well______--------------Disfdnce from fcundation_1----------------.Distance to nearest lot line------------------ Number of lines-----------------------------------Length of each line-------------------------------Width of trench------------------------•---------- Type of filter material_ = Depth of filter material____________________'Total length________________________-___-___-_ ----------- - Seepag it: Distance to nearest w I€ ___.______________Distance rom. undat:on___ 5______.D Stan erto nearest lot line._*_________ Number of pits_____.'___-----------Lining material-r __-Size: Diameter__3_X- _____.Depth_.._.tQ_j________________ Cesspool: Distance from hearestrwell------------------Distance from foundation_._.°______t-------Lining material-_--_-._.___--.____-.______._________- �� ❑ Size: Diameter. ---- ---- `- ------Depth----------------- •--------- __- Liquid Capacity----------------------------gals- Privy: Distance from nearest well-----------_--------------------------------------Distance from nearest building------------------------------------------ Disfance-fo nearest lot fine_ry'_____"____:____ - �- � - ❑ ------------------- - ----------------------------------------------=---------------------------------------------- X,-w I Remodeii anc! or re0airing describe):_ --___-- __ .----- --------- --------------- I = ------I hereby certify that 1 have-prepa ed this-application and that +he work will be.doge in accordance with San Joaquin'County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----- `------------------------------------•--------------(Owner and/or Contractor)By:—M_-w ---------------------------------------------------------•------------------=------------------------(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 APPLICATIONACCEPTED BYQ---------------------------------------------------- -----------------------•----•----------- DATE-Zv--------------------------------------------------- REVIEWED BY � J --I------,--:----------------------- - DATE — BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-------�i�------------------------------------------------- Alterations and/or recommendations:________________________________ _ - = -------------------•---.--------------------------- -•-----------------------------•------------------------•-•--------•-------------------------------------------------------- ----------------------•----------•--•------..-------------------------------------•-•-•-•---..... k -- ----------- ______________________________________________________________________________________________________________________________________________________________-._-__-_.-___________________.____._____--•--...__-_.___________ __-- ------------------------____________________________________________________________________________„_..__-____________--___-_-- FINAL INSPECTION BY:------- ---._i --- _-- ------------ ..�� 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 Revisaa 1-57 F.P,CO.