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F �L ,y PPLICATION FOR SANITATION PERMIT Permit No. ----- r �� (Complete in Duplicate) _�_ ______.��' 7�1 S'� Date Issued 2 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appiicatiori is made in compliance with County Ordinance No. 549. (,G JOB ADDRESS AND LOCATION---: h.:". r--- --,��rr._�._..�' -------- -------- ��-- --------------------------------- ------- --- - -------- Owner's Name--------- �?'`'O- ------- ---------------------------------- Phone__ p�1 �� /9- ----------- ----- -----------•------------- --------------------------- ----------------- -----------------------------.-__------------------------------------------•------- Contractor's Name = 1---- ----------ryyy G:u`. itC�h�S C Phone.. Installation will serve: Residence ❑ Apartment ouse ❑ Commercial ❑ Trailer Court [P Motel ❑ Other ❑ Number of living units: Number of bedrooms _F--- Number of baths :_'_____ Lot size ______3_ �___________________________________ Water Supply: Public system ® Community system ❑ Private ❑ Depth to Water Table Ja-_-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ® Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes A!] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) LL . -.s Septic Tank: Distance from nearest well___10:P_______Qistance from foundation_��"''�---____Material__ _______________________________ % M No. of compartments------Y----------------� �f x4 7---L"`�r�aLiquid depth 's- ---------Capacity-- �+,� Disposal Field: Distance from nearest well-./---------Distance from foundation_''`'-_____-Distance to nearest lot line_��.�_.___. Number of lines_____/___-_________---______ Length of each line--l-0_____________________Width of trench._34'�___--_ Type of filter -----Depth of filter material----I_r.'----------Total length___?_d______________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.___________._ j ❑ 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):--------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------;-----------•--------------------------------------------------•------------ ------------------------------------- t ------------------r---------------------------------------- ------------------------------------------------------•--•-------------------------- ---------------------------------------------------- - ------------------------ ----------------------------------- ---------------------------------------------•-------------------------•------------------------------------------------------------------ -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e laws, and rules and regulations of the San Joaquin Local Health District. (Signed- L ----------- {Owner and/or Contractor) By:._..----------------------------------------- ---•---------------------------------------------------------------------------------{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 APPLICATIONACCEPTED BY-- '- -- ---------------- ------------------------------------------ DATE _- p^' ------------------------------------ REVIEWEDBY----------------------------------------------------------------- ----------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------------------- Alterationsand/or recommendations:----------------------------------------------------------------------------------- ---------------------------------:---------••------------------------------ ---------------------------••------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ----------------------------------------------------------------------------.- ------•------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY,• / ----------- ---------------- Date_0/_-30------- __.�-•----------------------------------------------- _ _?!e_�a�,cls�1 -• 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 , Revised 1-57 F.P.CO.