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APPLICATION FOR SANITATION PERMIT Permit No. .�1.��..__ {Complete in Duplicate} /144 Date Issued ---- ----------r7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appl ca iori is made in compliance with County`Ordinance No. 549. 4 JOB ADDRESS AND LOCATION- __ r, ri,•� +C__--- --- - -- - .--- ---/ - ----------------- Owner's Name---- ----- •--- '------- -- ----- ----------------------------- --------------------------------------- Phone------------------------------------ AddressK.4_'r-__ � L� o�.��------ . �� 1---------------------------------------------------------------------------------------------------------------- Contractor'sName -------- -------------------------------- Phone----------------------------------- --------------------------------------------------------------------------- Installation will serve: Residence N Apartment House ❑ Commercial ❑ Tr iler Court [-] Motel [-] Other E]i Number of living units: _�_____ Number of bedrooms __ __ Number of baths __ __ Lot size __' _ '" ._ Water Supply: Public system ❑ Community system.❑ _ Private,k. Depth to Water Table k_0__ ft. Character of soil to a depth of 3 feet: S#nd ❑ Gravel ❑ Sandy Loam ] Clay Loam❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes Z No ❑ 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 r$7�b__------Distance from foundation-Z-0-------..--Material 4�-------------------------- �] No. of com artments____�_____________ Size__q"0 ' Li uid de th______ ____.__Ca Capacity !f6"°_____..___ P 9 P. p ty Disposal Field: Distance from nearest well._5�o--------Distance from foundation__/P- _.Distance to nearest to line___r-______-. Number of lines------ ___ _..________ Length of each,line__�,�7______ -' Width of trench__3' ________________________ Type of filter materia ?-____Depth of filter material__ !_________Total length__V,7, ___________________________ H _ ____ c from foundation__ ��_____._..Di/st nce to nearest lot line--- Seepage _______ Pit: Distance to nearest we I___L___________ Distan Number of pits_____-----------Lining materia __ _Size: Diameter_f-{t_` Dept h_e ' ______________ Cesspool: Distance from nearest well------j_.____ Distance from foundation--------------------Lining material_~-----.______.___.______.________. ❑ Size: Diameter _ - ' Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_4---------------------- ____________________Distance from nearest building__________.____________________.____..___. ❑ Distance to nearest lot+line-F--------------------------------------------------------------------------- -------------------------------------------------------- f 1 q 0 Remodeling anal/or repairing (describe:__, -- #_____-_ =-- x 1 I ----------------------------------------------------------------------------------------- -�-- - ,---------------- ---------------------_-----------------------------------------------------------____ J 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 Joaquin Local Health District. (Signed) ---------V------------------------------- (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}. f FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY, � r.? '� ----------------- -------------------------------------------- DATE-/*--- ------------------ REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE-- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------- Alterations and/or recommends 'ons•._-___--°_---•---------------------------------------------------------- - ----- - . � "'' - - . .: ----- -- -------- ----- -t` 3 = ;00 --------------------- ------------------------------------------------------------- ----------- -------------------------------------------------------------------------- e 2 FINAL INSPECTION BY-- Date---.r ^`� ~ Q----------------- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1.57 F.P.CO.