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4 APPLICATION FOR SANITATION PERMIT Permit No. (CompCom [ lete in Duplicate)p Date Issued ---- �_�. � Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordnance, No. 549. JOB ADDRESS AND ,LOCATION I �� !..= f` --------------------=-- --- ---•----------------------------•--------- � ..: , -- -------------- Phone--------- ---------....--------- Owner's Name = - ------ Address �' " r p ,_�r+{` � c.� --------------------------•----------------------------•----------- Contractor's Name--- ---------- .----•-----------------------------------------------------------------------------------------------•-------- Phone--------..--•--=-----------•------- Installation will serve: Residence M Apartment House ❑ Commercial ❑ =Trailer Court EliMo el [IO,tr}h r E] Number of living units:i_-:'_;Number of bedrooms _ _- Number of baths J-_- Lot size -C!--------------_-------.---- i Water Supply: Public system Community system ElPrivate E] Depth to Water Table -------- ft. `f x Character of soil to a depth of 3 feet: Sand E] Gravel L] Sandy Loam Clay Loam E] Clay E] Har Adobe 1- dpan C1Previous Application Made: Yes ❑I No I New Construction: Yes ® No ❑ FHAi/VA: Yes ❑ No.EW"' TYPE OF INSTALLATION AND SPECIFICATIONS: — .: ,- [No septic tank or'cesspool permitted if ublic sewer is available within 200 feet C , Septic Tank: Distance from nearest well .#0 Dista ce f�ro�m foundation-___--- • / - - Materi I o No. of compartments------ ----- --------Size _ ' _-� _._--:___Liquid depth____ -------- ------- Capacity.._. Disposal�ield: Distance from nearest well_160 i-Distance from foundation - Distance to nearest lot line--,.c----------- Number -------- Length of each line=-tID-40F4!CWidth of trench--------- -------------- T u e of filter meteria -_ ----- of filter mat erial-------- - --___ Total length----------- -- __----_-_-...--__ _�_--y--Distance from foundation__ __._._---____-Distance to nearest lot line----____-__----. Seepage Pit: Distance to nearest well____________ ❑ Number of pits-1- -----Lining material-----------------------Size: Diameter------------------ ----Depth--------------------------------- Cesspool: Distance from nest 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 (descrille):-------------- ---------------------------------------------------------------------...--------------------------------------- -.----------------•-- ----- ------------------ ----------------------- -------•-----•-----------------------------------------------------------------•- -------•---------------•------------------------------------------------ } ---------------------------=----------------------------------------------------------------- -� ---------------- ------•---------•--•---------------------•-------•--------------- -------•----------•-------------------•---------------------•---------------------------------------- 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.fr lu es and re ulations of the San Joaquin Local Health District. lpl y/ r � � r(Signe -- --------------=-------------------------------------- ---------------------------- e- [Owner and/or Contactor ) Vr BY� �C� ! =------------ _---------------- [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 _ ----=•--------1• T:. - __ DATE. -_ - REVIEWEDBY _ ------------------------------------------------------------- DATE---�------------•-----------------------•-••------------ BUILDINGPERMIT ISSUED--------------------------------------` ---------------------- ---------------------------------------- DATE---- .QA ----------------------------•----- Alterations and/or recommendations:----------------- l L - --------------------------•--•----------------------------- "A ------•- ---- •---•------•-- ----- -- ------- M -_ ------------- � t FINAL INSPECTION - --- _- -------- --- Date-----t F"--------------- 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 }.57 F.P.CO.