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APPLICATION FOR�SANITATION PERMIT Permit No. ..��.72.? (Complete in Duplicate) Date Issued ___ �r This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein;deribDed. This application is made in compliance with County Ordinance No. 549. °JOB ADDRESS AND LCATION. 1(! •-- -- -/—----------- ------------- Owner's Name------ ....... L Phone--------- ----•------•--- Address ---� l .-�- - -------- ---------- ------• •- Contractor's Name---,00-d'-w-U----- -----------••------- --- ------------------- ---------•-------------------------------- Phone....... •----------------•-•----. Installation will serve: Residence 2 t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _____ Number of bedrooms --3.- Number of baths -ge size ___ /- -- -•-- Water Supply: Public system ❑ Community system ❑ Private Z Depth to Water Table V-0 ft. i Character of soil to a depth of 3 feet: Sana* Gravel ❑ Sandy Loam,O Clay Loam ❑ Clay.❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No�77777 "````New Construction: Yes D4 No-O. FHA/VA: YesA No ❑ �N TYPE OF INSTALLATION AND SPECIFICATIONS: b (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Distan�e fro foundation---147 0-------Material-- ---------------------- Septic Tank: Distance from nearest well__+-_- No. of compartments--- IX --------° .Size �-�-_ -----Liquid depth-------t/-------- -------Capacity_� _--------------- s � I Disposal Field: Distance from nearest well-5�-�-____Distance from foundati in � '____.-._ Distance to nearest lot lina_�^�_________- ; ,� Number of lines _______._.___ �e -----`-----Length of each line-----it-- -------Width of trench---_�Y--'-- ---------------- Type of filter material kzkke-Depth of filter material____,�_�'--------__Total length__x71_ '__________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits---=------------------Lining material----------------------,Size: Diameter Defth Cesspool: Distance from nearest well________________Distance from foundation_-----------------Lining material-_.____-_______----____.__________ ❑ Size: Diameter--------- ----------------------------Depth_--------------------------------------- -----------Liquid .Capacity---------------------------gals. 1 } Privy: Distance from nearest well------ -------------------------------------------Distance from nearest building-------------------------------.________- ❑ Distance to nearest lot line-------------------------- --•----------------------------------------------------------------- I . t 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 rgaulations of the San,Joaquin Local Health District. ---------------------- (Signed) --------------------------------------------------------------------{Owner and/or Contractor) Title (Plot p&ze of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t�d FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ ,�` -------------------- ---------------- DATE -�- O REVIEWEDBY-------------------------------- ------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------- --------------- DATE------------------------------------------------------------ Alterations and/or recommendations:----------------------------- ------------------------ ---------------------------------•--•------------------------------------------------------ ----- - -------------------------------------------------- ----------------------------•-- ---------- --------- --------------------------------------------- -------------•---------------- - ----•------- ---------- -----• -------- --------•---------- -------- --------- ------------- ------------ FINAL INSPECTION BY�/ � . Date__1a_- .(-/------- -- 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-9-2A'l RE�vised B�'S9 F.P.Co. �,:-