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APPLICATION FOR SANITATION PERMIT Permit No. ..� a_. (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descrbed. This application is made in compliance with County Ordinance No. 549. ' R JOB ADDRESS AND LOCATION---=�--------- ------ '� ��s-ie----Owner's Name---------- _ ' --------- ------------ ------`------------------ Phone_ .L°_r- � Address-------------_----------� � �1` f 'L -------------------------------- ---'------- ---------------- .....------•-•---•-----••------------ Contractor's Name------------------Its�1 L1' -----------------------------------------------------_---------------------=: Phone.. �� =� � 7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms __ Number of baths__!__-. Lot size ______ __ __�_/i-__J _____________________ Water Supply: Public system PK Community system ❑ Private ❑ Depth to Water Table 3.47 ft. � Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ ClaytLoam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ;Z New Construction: Yes ❑ No FHA/VA: Yes ❑ No,® TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet:) Septic Tanl�: Distance from nearest well------- ------Distance from foundation--------- __' .:_Mater<ie4------------------ ----------------------------- - ❑,e-��r�y No. of compartments--------------------------Size--------------------------------Liquid depth------i- ----- -.---� Capacity...-.- --------- . . ,;,_ -- - / Disposal Field: Distance from nearest welhZa�t__Distance from foundation _/X/�---pistance to nearest lot l�e__�'�_--____. Number of lines___________ -. Length of each line_ _ __-Wydth"of trench_____ __ [� g -- ------- �r r- -------- Type of filter material __ ___ _ --------Depth of filter material_____1_4e___:__-__.Total length_________ ______________________________ Seepage Pit: Distance to nearest well_ ____Distance from undation___ _��.___.Di ar�ce to nearest lot liine._.�.----- of --Number -Lining material_� �+] ofpits._--_ -- -_- - -'C.�-_ -- -- -- ---Size: Diameter---,VX.,�W_&__Depth------------------------------ ' Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material-------------------------------------- 0 __--_:--_-_-._---.__________-__-___.❑ Size"t Diameter--------------------- --------------Depth------------------------------------ ------Liquid Capacity-----------------------------gals. _____________Distance from nearestz,buildin Privy: Distance from nearest well--------------------------- -- ------------------------- ❑ Distance to nearest lot linea ----------------=------------------------ --------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------•------ ----------------------- -------------------_•-------------------------------------------------------------------------------------------------------•------------------------------- ----------------------------------------------------------------------- -------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will-be done in accordance with San Joa461n County ordinances, State laws, and rules and,regulations of the San Joaquin Local Health District. $i ned n__ _ Owner and/or Contractor ��-� sY:-------------- i------------------------------------------------------------'---------------------------------------------------` (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__ _`o— REVIEWED BYE-- DATE------------------------------------------------------------ ---------------------------- PERMIT ISSUED------ - D ' E----------------------- ----------------------•------- Alterajonsd/or.recomme ations:___ _ _ �+�-- •------- -- - - --��--- . �� _ �'��-_- -67--- `� ---------------------- - FINAL INSPECTION BY:..-_-- --_<_-- - -- ------- ------ Date..... -r- - 6 ------------ -------- - - - -- 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 V59 P-P.Co.