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15 kiJ5 GS APPLICATION FOR SANITATION PERMIT Permit No. .. (Complete in Duplicate) Z Date_ Issued -__._�x�/..--� Application is hereby made to 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. r+,d 1,J 17(—. f Uf--0 f tray C +E ? �VTM - J c1 JOB ADDRESS A LOCAT ON:_: '__ r--------- f - -----Vt - - --- ---- - ----- ------------------------------------ Owner's Name / t // ---- -- - --- ---- ------------- ---- ------- Phone---------._.---------_----------- Address----- �1 Q. ��- r Contractor's Name " -' ,------ 01? —-- ----------------------------------------------------------- Phone_--------- _-------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other �C� / I Number of living units: �--- N ber of bedrooms , __ Number of baths Lot size ---��...... -------------------- 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 ge-flardpan ❑ , Previous Application Made: Yes ❑ No New Construction: Yes [?00`N�o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 fe t.) Septic T Distance from nearest well---Al Distance,from foundation- ------ M e iaL_-__- _ �i __Capacity_ _ No. of compartments.-- ---- - iq �d deptf----- ----------- j Disposal field: Distance from neares welL�"_� _-.Distance from foundafion-----A14--------Distance to nearest lot 1' :_ -_--__--- Number of lines________ ______________- -------Length of each line-------_3-0-1 Width of trench._ _ ' Type of filter materi I-------------------------Depth of filter material______ _ _ _. Total length____ --�-�1-3, ) ------ Seepa it: Distance to neares we11__ _____Distance from oundation__0........... to nearest lot line_ -_____ _ �, L Number of pits------ --------------Lining material Diameter-_._- _ �f Depth---__-'.. -----.��--- , i Cesspool: Distance fi•om nearest well-----------------Distance from foundation----------__._..----Lining material------------------------------------. _" ❑ Size: Diameter---------------- -- -----Depth--------------------- -----------------------------Liquid Capacity----------------------------gals Privy: Distance from-neares#well__.--.__.___„_-___ _ _ ________________ Distance from nearest building__-----.---._-- _______..__________- _. .� .> Distanceto nearest lot line------------------- ------------------=-- ------------------------------ - --------------------------------- - - --------- RemodeIing`61-T/or repairing (describe):--------------------------------=------------------------------------------.--------------------- -------------------•------------ --------------------- I ---•-------------------------------------------------------------------------------- ------ h = ----------- -- I certify p that I have prepared this application and that the work will be done in accordance with San Joaquin County ordina ces, ate laws,•and r and regulations f-the San Joaquin Local Health District. (Signed)---- -- " -----------------------------------------------------------(Owner and/or Contractor) By. s}ISv�ci g size of lot, location of sys+em i lation ------- -----(Title ):. (Plot plan, to wells, buildings etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- --------------------- ---------•------------------------------------------------- DATE---------------------- ---- ----- REVIEWEDBY--------------------------------------- ------------ - --- ------------------------------------------------------------ DATE--------------------- - ------- BUILDINGPERMIT ISSUED------------------------- -- -------------------------------------------------------- DATE------ --- -- ----- ------ --------------- Alterationsand/or recommendations----------- - ------------------------------ -------------------------------------------------- -- --- - ----------------------------------- - = - ---.----- ------- -4 -&- ----- ----- --------- 10- vP --------------------- -- ------------- ---V---___--- -- 4Z ------------ ----------------------------------- -- --------------- - 1 FINAL INSPECTION BY-------------------- -- ------ ----------- ---- Date------------ ----7--�-------C--�----------------------------------- SAN JOAQUIN LOCAL H ALTH DISTRICT 130 South American Street 300 West Oak Street f 32 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy. California ES-9-2M Revised 1.57 F.P,CO.