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ArPLICATION FOR SANITATION PERMT Permit No. -lgG)__S._ (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 describ-4 This application is made in compliance with County Ordinance No. 549. �t1�tJJT ✓ -_//// van w�-cc� JOB ADDRESS AN ATION------- ern _..- ----L .-.C... -------P`iJl./7hone -----J13------��tf;rf,_4�,✓ Owner's Name-------- Y 1 C --------- �- 1 V/�------- '��3-�" - - .� e-�--��--�------- --- - -------------- --------------------- Address-------------------------------f?/s � Contractor's Name--------------------------/co `�--•---•---��-5=Q Y_'C' ------------------------------------------- Phone----l__ -_�—1111/.4 Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other L 'Se, ✓ice- Sf«f"iu�- Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ----- -__.`~......................... Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table J&`.- ft. Character of soil to a depth of 3 feet: Sand n Gravel p Sandy Lo;'t ay Loam ❑ Clay ❑ Adobe❑ ardpan ❑ -- Previous Application Made: Yes E] No New Construction: Yes ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public s wer is available within 200 feet.) ....--Distance from foundation___ Septic Tank: Distance from nearest well_. v �12.I- ...Material-_-_- j�_�Y.l - ___.-_-_. No. of compartments q p -_______Capacity-/I P �----�-------Size.�.S_�X�l�-?�-------Li Liquid de th------�-- �-- / -------- Dis osal Field: Distance from nearest well-SV----------Distance from foundation--.,_�4---_-----_-Distance to nearest Iodine-5_---_r- Number of lines-------------3...................Length of each line----)_D-Q------------------Width of trench--- `(-_ ----------.---_-_--- Type of filter material.-_. --------Depth of filter material-----J_4{---.----------Total length_-.. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot lune- ._ ❑ 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------------------------------------------ ElDistance to nearest lot line------------------ ------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):----------------ry.Lc.0-.------- - �-------- •--- - - -- ----------------------------------------------- --- ----•-----------------------------------------• •- --------------- ----------------------- - - ------- -------------------- - J b" --------------------------------------------I------------------------------------------------------------------------- --------------------------------------- ------------------------------11------------------------------------ ----------_---------- 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County C ordinances, State law and rules d ulations of the San Joaquin Local Health District. (Signed)------ -------------- ---- - - -------- / -...(Owner and r Contractor) By:. ---�1 L�---- - -------(Title) 1 - (Plot plan, showing size of I t, location of system in relation to wells, buildin c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------------------------------------------------------ DATE------- I -----A ---------------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- -------------------------------------------- -------------------------------------------------- ------------ --------- ------------------------------------------------•----•----------------------------•--------------------------------------- ---------------•----------------------------------------- ---� - --------------------------------------- -------------------•--------------------------------------•---------------••-•-------------- FINAL INSPECTION BY---------- -- 1 - -'v- Date------------ ----�---- �:�-------------------------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1-57 F.P.CO.