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R APPLICATION FOR SANITATION PERMIT Permit No. (Complete.in Duplicate) �//_Sq Date Issued ---- s Application is hereby made to the San Joaquin Loc�l-Health District for apermit to construct and install the work herein described. This application is made in complianceIwith.County Ordinance No. 544. - y. JOB ADDRESS WD LOCATION__1-14-7`7 ------�------- L = Owner's NameJ'' `J..- = -- ------------------------ lPhone-- - ----------- Address---------- - =�--------)_ = Contractor's NameJ-------4-G�s r'— --•---------------------------------------------------------�---------------- ----------------- Phone----------------------------------- Installation will serve' Residence Qj/Apartment House ❑ Commercial ❑ IT -Court ❑ Motel ❑ Other ❑ Number of living units: .-I___ Number of bedrooms __ _ Number of baths ___/___ Lot-size 614_ x---1 o-------------------- Water Supply: Public system jk 'Community system ❑ Private []..-Depth to Water Tabble 3- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ AclobeV Hardpan ❑ i Previous Application Made: Yes ❑ No [�' New Construction: Yes j(No [f FHA/VA: Yes ❑ No / ` # TYPE OF INSTALLATION AND SPECIFICATIONS: I ! Septic Tank: tapk or'cesspool.per:mitted,if,public se ris available within 200 feet.) o ' p stance from nearest well _ , Z lance from foundation---I_�Q_* �:_.MateriC ° No. of compartments_ _ _ _____ Size__ __ __ Li uid de fh__ _ _Ca acif Disposal Field: Distance from near t welll�� tance from foatiDistance to nearest lot line_________ Number of lines-- f --_----------------------Length of each Fk - �1Q�_ 1Nidth of french________._____________ ------------- Type of filter material-------------------------Depth of filter material-------------------- length------------------------------------------ Seepage Pit: Distance to nearest weft----------------------Distance from foundation-----------------_.Distance to nearest lot line_________--__-___ \ ❑ Number of pits----------------------Lining material-----------------------Size:•Diameter_-----------------i-Dept h--------------------------------- Cesspool: Distance from nearest well_________________Distance from rfoundation-----------------1_.Lining material------------------------------------- ---------..De th--------------t_ 11•�-� Liquid Capacity gals. � ❑ Size: Diameter--------- ------------- p --------- - ---------------- q p tY--------- ----------------9 1 � l/rN Privy: Distance from nearest well------------------------------------ ----- ------Distance from nearest building-------------_---------------------------- ❑ Distance to nearest lot line-- --- ---------------------------------- Remodeling --------------------------------Remodeling and/or repairing (describe):------------------------------------------------------------------------------- ------------------------------------- ------------------------------------------------- -------------------------------=------------------------------------------------------------------------ ---------------------------------------------------------------- F __.__.______________________________________________________________________________________________________•-_...___________-________________.______________.________________--________________._._____----___-________.____._ 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 and regulations of the San Joaquin Local Health District: (Signed) --------------- -----------------------------------------------------(Owner and/or Contractor) By: �- ---------------- ---------------------•-------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing siz'e of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). { T 1 FOR DEPARTMENT USE ONLY ; APPLICATION ACCEPTED BY__.`_'--•--- _r--- --- ----__ t DATE - -- --------- --- -- -- -- - ------------------------- REVIEWED. BY-------------------------------"-- -- -- - =--------------------------- DATE--- �r BUILDING PERMIT ISSUED------------------- ------------------- - --------------------- DATE- Alterations and/or recommendations________________________ _____:________- ---- -------------------------------------- ------------- t - --------------- ------------- 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-9-2M Revisea 1.57 F.P.CO. a 1