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qq APPLICATION FOR SANITATION PERMIT Permit No. l._- 1. ... (Complete in Duplicate) Zr- 11 Date Issued ___!/:I,/J_� Application is hereby made to the San Joaquin Local Health District for a permit to construct and instail the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION----------/ -------- --------------------------------------------------------------------------------------------------------- Owner's Name ...... ----------------------------------------------------------------------------------- -. Phone-------------------------- Address------------------------------------------ _LSJ-e(/G- - ------------•-----------••--------------•----------------------------------------------------------------•-••-------•-----------------------. Contractor's Name---------------------- C?!?.Gi1 N ------------------------------------------------------•-----------•-----------•--•----- Phone------- ................---------- Installation will serve: Residence M/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑J Number of living units: -]----- umber of bedrooms --l- Number of baths ________ Lot size .-__._-- Water Supply: Public system /Immunity system ❑ Private ❑ Depth to Water Table -------- ft. s Character of soil to a depth of 3 fee Sand Gravel ❑ Sandy Loam Clay_ Loam ❑ Clay ❑ Adobe �ardpan ❑ Previous Application Made: Yes No New Construction: Yes �o ❑ FHA/VA: Yes [] No TYPE OF INSTALLATION ANb PECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: f Distance from nearest well-----------------Distance from foundation----=--------------Material---------------.-----------------------______-. ❑ ��1J No. of compartments--------------------------Size---•--------------------•-------Liquid depth--------------------------Capacity-------------------; I Disposal Field: Distance from nearest well-400------Distance from foundation-----I_Q___r-----Distance to nearest lot line-_-3_ [� Number of lines----------___. _____Length of each line_______�s__-------_-----_Width of trench-------- -- -------------------- -________-.______- Type of filter material-___ ra,� Depth of filter fnaterial____---C_ - g ---- ------------------- ------Total length---. '� Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______..___._____ ❑ �/�� Number of pits----------------------Lining- material-----------------------Size: Diameter-----------------------Depth--------------------------------- p� Cesspool: Distance from nearest 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 (describe):---------------------------------------- -- , ----------------..._.. ------- ------------------OR � -------�""1..� --------��_r-��------ r�s��. �.�� Q A 7-.n'7..----------. --- ------------------•-----------------------------------------------------------=----------------------------------------j-------------------------------------------------------------------------- ---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ 1 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 aq-vtions of t e San Joaquin Local Health District. {Signed)-�-•--• � -----I ----I --------------------- ----------------------------------- ----------------------------------(Owner and/or Contractor) By:----------------- ---------- --------------------------- ------------------------ ---------------------------------------------(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.-------------- ----------•-----•--------------- ------------------------- DATE. . . REVIEWED BY-------------=--------------------------- -- - ------------------------- ---------------- {}� �------------------------------------------- BUILDING PERMIT ISSUED-------------------- ---------- ------------------------------------------------------------------- DATE-- `'F --------------- ------------------------------ ' Alteratns a d/or re mmendatio�---------- - -- -----------------------------------------_-- -------- r ------ �- ---------------------- ------------------------------------------- - ------------------------------------ ------------ ----------- � � FINAL INSPECTION BY:. Date ` ZSAN 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 1.57 F.P.CO.