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APPLICATION FOR SANITATION PERMIT Permit No. .,,td:J'.._./..� � (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 LOCATION---:------ -- ---- .-- ------- --- ---------- -- -- -- --------- w Owner's Name---------------.'_. �:---------'--�-`<��< -------- ---- --- - ------------------._._._ - Phone-...---------------------------------- l 0 Address----------------------------------- -. - -- R'4 Contractor's Name-------------------------- 'y -' lr�e -' - "'r'',, hone_ .. _ �'-- Installation will serve- Residence �partment House E] Commercial E] TrailerCourt ❑ Motel E] Other ❑ Number of living units: - _._ umber of bedrooms __44•-Number of baths ---/_ Lot size ------ ?L. __------___-_-_-_ Water Supply: Public system Com, system ❑ Private ❑ Depth to Water Table _irt. of Abet: Sand Gravel Sand Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Character of soil to a depth � ❑ ❑ Y ❑ --ttY - Previous Application Made: Yes 0 Nj V( New Construction: Yes ❑ No�` FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if pubic sewer is available within 200 feet.) Septic Tank: Distance from nearest wellNJ!.Distence .frog foundation__,_____ Material.,________ ___ _ _ _ No. of compartments___ _��_f_ Size_ _= ---Liqu d depth _ i- ` ---•-----_Capacity Disposal Field: Distance fromnearest°welt__ AWG-Distance~from-foundation-=5& -_..Distance to nearest lot line f/--___-___-- AK Number of lines- ------ .---- -__y__Length of each line-----�jA__ _rr_i__ Width of trench__ --i __ _________________ Type of filter material___ _--Depth of filter.:material___,l___.___--'---__Total length___-_____.Cr_----_______-__________- \ Seepage Pit: Distance to nearest well__ W?-<,C'_'Distance from o pdation_ _ Distance to nearest lot line________.. Linin mate p � g material --�---�.~�_Size;�.Dia�et�--- --------,Depth------ ��------------------ K 1Numl3er of its_ ' twining material Cesspool: from nearest well-----------------DDetance from foundation _.___ P - _ _ I th-----------�----------------_-__t----- -!-----Li Liquid Capacity_ -- ---------gals. EE P -. --- � q P Y- - -- ---- Privy: Distance from nearest well-------------i------i--------------------------Distance, rom nearest building------------------------------------------ Distance ________-.-______- _---____:___-- Distance to nearest lot line___________ __._.._ -_- € Remodeling and/or repairing (describe)------------------------ --------------------------------------------------------- -----------------------------•----------•------•-----•---•-------- i 1 t I hereby certify that I hav prepared this pl' tion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r s nd •egula ' j the San Joaquin Local Health District. (Signed) 4 -- - Owner. ars/or Contractor) --` Title---- " (Plot plan, showing size of lot, location of system in relation f wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -•------- --- -------- ---- -------------------•----------- DATE---- I") REVIEWED BY----------------------------------------- -- - - - -- •-------------- ---- DATE--- /, �-J---4..- ---•-------•- L� ------ DATE----------------------- BUILDING PERMIT ISSUED. - - -- --- --- ------ Alterationsand/or recommendations--------------------- ----------------------------------------------------------------------------•---------------------••-•-•------•---------------------- --------------------------------- ------------•--•--•------------------------------•---.---------------...-------------------•-•---------...-----------------------------------------------------...---------................ ------------------------------------------------------•---•-----------------------------------------•----------------------------------------------------------- ----•----------------------------------------------- 1-� .- J_ FINAL INSPECTION BY:------ / Date ---- 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-17-2M Revisea 1-57 F.P.CO.