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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ___ /__ _S7 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, 11 —WOE LOCATION____3u1V-j__ -- _F $ 4. /y , f - c -- --- ---- .. '---------------------------------- Owner's Name--- �- .-(. �f -- --------------------------------------------------- ----------------------------- --------------------- Phone Address-------- ' = ° f ---- -- - - ------------ --------------------- Contractor's Name_-____ `2'o___ .. k a - --- - ------------------------------ ------ --- ---------• Phone.l)t� _"T "! 'T7 Installation will serve: Residence X partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.!�__ Number of bedrooms Ao Number of baths __.1___ Lot size ------- Wafer ___--Wafer Supply: Public system ❑ Community system [❑ Private A Depth to Water Table �!G?_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam D Clay Loam Clay E] Adobe E] Hardpan ❑ Previous Application Made: Yes E-1No El New Construction: Yes ❑ No E] FHA/VA: Yes ❑ No ❑ 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-----------------Distance from foundation--------------------Material El No. of compartments--------- ---------------Size--------------------------------Liquid depth---- _._-- ---------------------- Capacity le - �-+ I Disposal Field: Distance from nearest weil_JZ)-------- Distance from found ation___��- _____.Distance to nearest lot line-A4-------- E(4 Number of lines__________ _____.______- -------Length of each line-___«G_�____ ___________.Width of french,< -�'-_-------__----_ ---- Type or filter material_' �. ---------Depth of filter material__/�-------------Total length-----;Zig_-/------------- __________ Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________.Distance to nearest lot line-_____.._________ ❑ 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--------------- Remodeling - -----------Remodeling and/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, State laws, and rules and regulations of the San oaquin Local Health District. (Signed)--------------- ---- -- --- --- --- --- __/_O✓h!�--- --- -----1�i-.C.---------- ---------------------------------------------(Owner and/or Contractor) By- ------- ---------------------------------- ------- ?------ ---- �- ---.--------------------------------------------------- {Title) p��._�� - - ------------------------------------(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___ - _ ---------------- -------------------------------------------------- ________________ DATE-------- - - _"- - REVIEWEDBY------------------------------------------------------------------------------ --------------------------------------------- DATE--------------------------------- ------------------------------ ------ ----------------- BUILDING PERMIT ISSUED--------------------------------- ------------------------------------- DATE --------------------------- terations and/or recommendations:_____________________ ------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY: -------------------------------- Date-'y 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 , Revisea 1-57 F.P.CO. � T