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APPLICATION FOR SANITATION PERMIT Permit No: ._�6__3_ __ (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 --------- ----- -- 1 " Owner's Name_.__ --------------- PhonA_j_P_,?9_7_y Address-.----------, _ t "i Contractor's Name----. tcrx: ------------------ ------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence -Rj Apartment House C] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 4r Ak Number of living units: /------ Number of bedrooms _r -_ Number of baths -1----- Lot size .-- - ----_ _______________________________________ Water Supply: Public system ❑ Community system ❑ Private, ] Depth to Water Table (,t__ ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 4 Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes % No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) _ _-'l�'� Septic Tank: Distance from nearest well--_0!__Distance fro f undation-_ G p 1�------------Mat ,al----------------------------------- ---------- '� No. of compartments---- -'lr3Wu Capacity---,paD_._._..___ -----_---Liquid depth ----- _ Disposal Field: Distance from nearest well__--ts�'-_-Distance from foundation___./.4__'-....--.Distance to nearest lot line__75 --------- Number of lines.---1__ ' - -------------------Length of each line------Z,rt_�--.-----_...--.Width of trench--.7a�'----------------------- I, �er1�____._.._Depth of filter material__/ --------------Total length_.;_:_ Type of filter materia .- - Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material------------------ ----Size: Diameter-----------------------Depth-.------------------------------- 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------------ ----------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):-------------------------------------- ------------------------------------------------ -------------------------------------------------------- ----------------------------------------------------- -------------------------------- ---------------------•---------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S��tajjt��err laws, and rules/and regulations of the San Joaquin Local Health District, 4�[Signed}-----`!_Yv "-�!__4-f________ ________ (Owner and/or Contractor) B _(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_,/,&9 DATE-_4 °z- REVIEWEDBY--------------------------------------------------------------------------------------------------------------------- ------- DATE------------------------------------- BUILDING PERMIT ISSUED--- --•---------------------------------------------------- ---------------------------------- DATE----- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------- ----------------------------- ---------------------------- ------------------------------------------------------------------•--------------------------------•-•--------•--------------------------------------------------- ----------------------------------•--------------------------------------------------------- ---------------•-----------------------------------• ------------------------------------------------------------------------- J FINAL INSPECTION BY ----------------- --- ----------- 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 E5-9-2M Revisea 1.57 F.P.CO.