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e �1 APPLICATION FOR SANITATION PERMIT Permit No. ` (Complete in Duplicate) Date Issued 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 No. 549, JOB ADDRESS AND ��LOCATIOfN/ 1 -¢-:. _ = J - Owner's Name {G✓� E ----------------� ------------------------ ----------- Phone n� • Address.-------------- ---p�'f-�---------------- -•-- _--- � .. - -- - - ----------------------------------- Contractor's Name --------------------------------------- Phone Installation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms __ Number of baths __/__ Lot size _d�--____.___________________________"_____________-- Water Supply: Public system [�} Community system ❑ Private ❑ Depth to Water Table _�� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ®1FHA/VA: Yes ❑ No ❑s---- } TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well------- �--__Distance from founclation__� /_____--Material---- _ _ 2 ___________________ No. of compartments......... ---'7"e--:--•Liquid depth---- ------------Capacity......7100--___ Disppsal Fiejd: Distance from nearest well.- --------------Distance from foundation--------------- --..Distance to nearest lot line_______-___._--- �i'"rj Number of lines-----------------------------------Lengthy of each line------ ----------------------Width of trench------------------.---------------- ✓ Type of filter material- -----------------------Depth of filter material_----------------------Total length------------------------------------------ 5epage Pi�: Distance to nearest well------ ---------------Distance from foundation_ ____.---_______.Distance to nearest lot line----------------- h7fV'r/I Number of pits---------------------Lining material-------------------"!.Size: Diameter-----------------------.Depth--------------------------------- 4, Cesspool: Distance from nearest well_ ______` .__Distance from foundation____-________._"-_.Lining material________--_"_________________ ___" ' ❑ Size: Diameter-------------------------- ----�__"Depth------ Liquid Capacity----------------------------gals. Privy: Distance from nearest wel!----- ---- -------------------- __._______ "_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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) Contractor) - ----------------- ----� --• -- a `� '------- Title ,&Z—eZ/r�7 ---•----------------------- - (Plot plan, showing size of lot, location of tem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ---- - -- ------- ------ ---------------- ---Y------------- DATE---------- -- REVIEWED BY ----- DATE----- ------------------------------------------- I 1 [------------------------------- BUILDING PERMIT ISSUED---------------------- --•- - ----- ---------------------------------------------------------• DATE------ q - - ---- Alterations and/or recommendations:---------- ------------------------------------------•----------------------------------------------------•-------------------- ---•--------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- ----------------------------------- ------------------------------•------------------------------------------------- ----- ---- ----------------------------------------------- FINAL INSPECTION BY: - Date. ---,l---I. )-------------------------- 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 . Revisea 1-57 F.P,CO.