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APPLICATION FOR SANITATION PERMIT Permit No. ._f __ t (Complete in Duplicate) L1(I � 91 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. S49. 0, 2.E !`70 :Z.3}7"7 f S. .�i Com.'-77s:.J�. .�✓J� , JOB ADDRESS AND LOCATION____ ,�_. � ----- - - ---------------- w Owner's Name �L;��E�hree.. Q�`�(rll`s1r -----� ----- ------------------ Phone Address - r� �� p �r ' ---------------- ------------------------••---••------._...---.. Contractor's Name--------------------- - -•------------------------------------------------------------------ -------------------------------- Phone------------------ ----------- Installation will serve: Residence l Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑Other ❑ Number of living units: J--- Number of bedrooms -5--- Number of baths _� t size _____!t_-_l��---------->e ►______________ i Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table fid____ ft. Character of soil to a depth of 3 feet: Sand ❑, Gravel ❑ Sandy Loam g] Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes E] No ;�G New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if pubc sewer is available within 200 feet.) e "^ SepticTank:, Distance from-nearest well _?% ,.Distance,from foun Latron_.: i No. of compartments---------lr---------_SizeA�X_ �J�__ 1-- ---Liquid depth____-�----------------Capacity___ , - - --- Disposal Field: Distance from nearest well_ .ywDistance from foundation-_/ Distance to nearest lot - Number of lines-_________etl - Length of each line...... .----_--___.Width of french---_- 1* ,� Type of filter material__S� __ ___ Depth of filter material----- Total length-------- --------------------- Seepage --_------- --_.Seepage Pit: Distance to nearest well----------------------Distance from foundation-------_._..........Distance to nearest lot line--._--_-_ _._-_._ w ❑ 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 and/or repairing fdescribe)--------- ----------------------------------------------------------------•---•------------------ -----------•----------------------------------•--------- ------------------------------------------•------------------------------•---------------------------------------------------------------------....-------------------•----------------------------------------------------- - ------------------- -------------------------------- --------------------------------------------------------------------------------------------••-------------•---------------------------------- 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)----------- '---------------------------------------------------------------(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). >r�ARTMENT�USE O. LY APPLICATION ACCEPTED BY----- = �� ------------- --- ---------- ATE 3 REVIEWEDBY------------------------------------------------------------------- ---------- ------------------------------------------------ DATE BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterationsand/or recommendations----------------------------------- --------- ----------_------------------------------------------------------------- -----•------------------------------ ------------------------------------------------------------------------------ - ------------------ ----------------------------------------------------------------------------------- ••-------------------•----------- -------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------.------ ---------------------------------------------------------------------------------------------------------- .. 4�eFINAL INSPECTION BY:. Date--------- ----------------------------•-----------------•---------- 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-9-2M Revisea }-g7 FY CO.