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APPLICATION FOR SANITATION PERMIT Permit No_ ___ (Complete in Duplicate) / / Date Issued Application is hereby made to the San Joaquin LoceI 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 LOCATION_. _._- ---- �_ p r Owner s Name_----- -- � � � ------------------ --- Phone Address__.--------- - 7 6 ry. 1 Q = -------------------- ------------ -------------------------------------------------- --------------------------------------------- ontractor's Name,"___ ,. _ - -- -------- ------ - ---- nsfallation will serve: Residence p - - - r """`""" Phone------------------ 1 �T artmenf House ❑ Commercial ❑ Trailer Court ❑ Motel �J'`r'�"'•i_ Number of livingunits: _-_ ❑ Other Jr, Number of bedrooms -------- Number of baths -------- Lot size . Water Supply: stem Publics Y E] Cammur;ity system ❑ Private Depth to Water Table ______"" ft. Character of soil to a depth of 3 feet:! Sand❑ ravel ❑ SanBy Loam Clay Loam ❑ ClayAdo I Previous Application Made: Yes No �Construction:� ❑ be ardpan ❑ ❑ New Yes No ❑ FHA/VA: Yes I] Na ®� 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 ___- _bistance from foundation____._____ 171 . ---------.Material - No. of c'ompartmenks------------------- ---•�--Size---"---•--------- --------------�iquicl depth-------------- Disposal Field: Distance from nearest wellCapacity f p Y--•--------=---------- _-_"._____.__,.-':Distance from foundation--------------------Distance to nearest lot line.___.'__._..___.. ❑ Number of lines_____________________' ----- --- -Length of each line------------------------------Width of trench------------------------------------ Distance --- ------- -------• --• Type of filter material___________ _.____ epth of filter material____ ------""- - --._Total length--------------------•---------------.----- Dis#ante to nearest well__ ___�4------Distance rom f undation__ J� _- OL {__------ _.__Distance to nearest lot line_-a`?" Number of pits---- ------------Lining material__---Size: 1�' er_ _l __ Cess o . /��------ Depth-----.,.rte'----- S p Distance fi fe nearest well _ from foundation-__---_---------_--Lining material-------------------❑ �5ize: Diameter - iDepth ---------------------------------------------- ----Liquid Capacity- gals. a Privy: Distance from nearest well______.__--"-_ bistance from nearest buiidin ❑ Distance to nearest lot line--------------r-•- g"" - ------------------------------. -- Remodeling and/or r airing {describe):_----- ------ -- ------------ - - ----------- + ------ --------------------- - -------- -------------------- --•----------------------•------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Caun ordinances, State laws, and ules and r gul 'ons o the San Joaquin Local Health Disfrict. e' xsig ned)----- r ` r -----------•- -------------------------------------------------------------------(Owner and/or Contractor) (PlotBY: = =-------------------------(Title)--------------------------------------------------- plan, showing size of lot, location of system in relation to wells, buildings; efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____.__.____ -------------------------•---------------- DATE--------------------------- -------"___-- - . BUILDING PERMIT ISSUED -- REVIEWED BY ----------------------------- -----""",-. ---------------- DATE----.------ -- ------------------ DATE-- -----------------DATE__ - -----------------•---------•----------------------------Alferations and/or recommendations: -------------------------------------- - ----------------------------- -------- t " 'l -- ----- , _1-�----- q�---------� 6 _--- Y �d J FINAL INSPECTION 8Y: �-_' _�_.��------ ,! _. �:,v --- ----•--- � ..Date.......... �: 3f, ,. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California " Tracy, California E5-9-211 , Revised 1.57 F.P.CO.