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AFPLICATION FOR SANITATION PERMIT Perm�fi No_ _____------------------- AP ' ___________ '-• (Complete in Duplicate) Date a issued Application is hereby made to the San Joaquin Local Health Distric# for a permit to construct and install the work herein described. This application is made in compliance w- h o4nty Ordinance No. 544. f JOB ADDRESS AND LOCATION--- --`------------. M•---•------- ---= --------------------------------------------- '------------------------------------ Owner's ------=---- --- -Owner`s Name-----------'------- -------------------------'__t-------- - ------...---------------- ------------------------ Phone------------------------------------ Address —�------------------------------------------------------------ ---------------------------------------------------------------------------------- ------- ----------------------- ----------------------`' f (J Q �7 Contractor's Name ------ "�" '+ +� .�-- E ' Phone Installation will serve: Residence m�parti"rient House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ; Number of living units: ---/__ Number of bedrooms ________ Number of baths t size ____ r Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water-Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑Clay Loam ❑ Clay ❑ Adobe 2--Hardpan ❑ Previous Application Made: Yes ❑ No 2-�New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No E]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_ #2 )_Distance fro t dation_ P___------Mater:i l--___ ____ _____. L No, of compartments----�---------------Size_,:,_7.�_ -------r-fir .-.---Liquid dep.th� !--------------CapacityT------ -.__� ------Distance to nearest lot line--,- Disposal C J Field: Distance from nearest well__ .�:11�-._.Distance from foundation___ � Number of lines_________________________ _____Length of each line'____'�_�_.�__F._..Width of french___�LO_______________- t Type of filter material_ 1A'r_-0r^__Depth of filter matena!___ f___.-Total length_____ _, --------- + SeepagefPi#: Distance to nearest well__ ' . `fI-_Distance from foundation....................Distance to nearest lot lin ---------------- I Number of its----I -------Lining material__Pi�. -------Size: Diameter__..,_ Deptn____ _-J—__--__________ Cesspool: Distance from nearest well-----------------Distance from foundation.---------.---------Lining material-------------------------------------- 0 ❑ Size: Diameter------ :--- --- ------Depth----------------------------`----------- ----------Liquid Capacity----------------------------gals, Priv Distance from nearest well_____________________ __Distance from nearest building ❑ Distance to nearest lot line------------------------------ -------------------------------------------------=---• ---------------- ---- ------- Remodeling anal/or repairing (describe):-----.---------- ----- ---- ------------------------------------------------------------------- -----------•---------------•----------- ----------- ----------- ----------- ----------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ----•-------------------------=--- ------------------------------------------------------------------------------------------------ --- ------ -------------- ------ ----------- 4 -- -------------------- ---------------- -------- -- ---- ------------------- 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 rules a r i of the,San Joaquin Local Health District. Septic Tank Service /� /� (Signed]________._ ,.___._.. ---------- ------------------- (Owner--and/-or-Contractor) ,� ----- -�o:�Tiiorciilo--FiC�2 7t�4Ti -- ----- � BY= = -St,3ckt n,_Calif------------ ---- / (Tittle)---A tt_ �---------------- ------------------------ (Plot plan, showing size of lot, location of system in.relation to w�4 buildings, etc{ can be placed on reverse side]. 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------- --------- --------------------------------------------------- DATE---- ------------------------ ------------------ REVIEWED BY DATE - -----�- f --•--------------------------------- BUILDING PERMIT ISSUED----------------------------------------- ---- ------------------------------------------------------- DATE------------ Alterations and/or recommendations:----------------------- ---------------------------------- ----------------•-----•-••------------ ------------------------- -- ___ ` S______________ _-_________ --- ___ ___ - _ _ ----------- ____.... ------------------- r�r7--------- ------------------ ---- ----------------------------------------------------------------- ----- ---------------------------- ---------------------------------------- •--------------------------- ") 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---•4-2M , Revised 1.57 F.P.CO. _ t�