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APPLICATION FOR SANITATION PERMIT Permit No. (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 LOCA ON_... ` r � � - ---- Owner's Name----------- e ---• Q -------------- Phone AddressNr!}--------•----------------------- ----- •--------------- --- ----------- -------------------------------- Contractor's ----••-------------------- ll// Contractor's Name - � T Phone ---- -------------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---- 1-- Number of bedrooms -_y-- Number of baths -Z-- Lot size ------ k ef-er�.�( Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table __f' ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ej Hardpan ❑ Previous Application Made: Yes 4 No ❑ New Construction: Yes ❑ No K 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 ------------------- .Materia{ ___-________________________-.______--_ El No. of compartments -------------------------- Size ------••-------------------- --- Liquid depth -------------------------- Capacity --•-------------------- Dispos I Field: Distance from nearest well--- ------------- Distance from foundation____ p_ f_____ -Distance to nearest lot line -46 --------- l WL ,r Number of lines --------------3 ------------- Length of each line ------------------------------Width of french--____- -- Type of filter material__-i?aez-�--------- Depth of filter material ---- -�--------- Total length ------ ZQ_---- ______ ----------------- 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 ---------------------------- __---.--- . El Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid Capacity ----------------------------gals. Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ---------------------------------- Disfance ------------ Distance to nearest lot line----------------------------------------------------------- Rep odeling andor repairing (describe) --------- • ------------------ t„�. y sits -- -------•----------------------------------------------------------••----------------------------•------------------------------------------------- ---------------------------------------- - -------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ 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 J quip Local Health District. Si ned s { 9 )--------- ----- - -------------------------- ------------------------(Owner and/or Contractor) By: - ------ - ------------------------------------------------------ (Title) ------ LLP--P"'� r't --•-------------------------- (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 a APPLICATION ACCEPTED BYT. wj DATE_ --------------------------------------------------- -------------------------------- BY---------------------------- �. BUILDING PERMIT ISSUED — DATE�--------------------------- ------------------- Alterations and/or recommendations:--------=--------------------- ---------------------------------------------------------------------------Cf-1- ---- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:------ Date---- --/� �aWJ7 SAN JOAQUIN LOCAs. HEALTH DISTRICT 130 South American S}reef 300 West Oak Street 132 Sycamore Street Stockton, California Lodi, California Manteca, California ES -9-2M Revisea 1.57 F.P,CO. 814 North "C" Street Tracy, California