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_ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / y y 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 w��ii-tth County Ordinance No. 549. � JOB ADDRESS AND LOCATION-----4J__ ---__ .- ---------------------------------- ------- ---------------- Owner's Name------ ---- ------��Lss_------•----------------- ---------- ------------------------------------- ------ Phone-��-�`�/..��----- jjAddress Contractor's Name--------------------7;�-?--------- --------- `' ' f Z2---------------------------------- Phone----------------I----------•------- Installation will serve: Residence [0/ Apartment House ❑ Commercial ❑ Trailer Court ❑ MotelE r Oj5� Number of living units: _/---__ Number of bedrooms ____4_ Number of baths ___l__ Lot size __ C�Ie� ----------------------------------------------- Water --------------------- Water Supply: Public system [/Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No R]/ New Construction: Yes ❑ No B"' FHA/VA: Yes ❑ No 0-'_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) , Septic nk: Distance from nearest well__ istance f om foundation__f�__-_: "-,.lvlat i I ke .--------- �f '( - �--- No. of compartments---------4'_—.____-:--Size---�-K--�____,�-:---Liquid depth--_----�-------------Capacity---Q___ _------- Dispos Field: Distance from nearest well----!`-----`- istance from--foundation= ��-j_____Distance to nearest lot In`e____ / Number of lines_________--:_ Length of each line----- ---_7_.___.Width of trench__ _� ---------- -Depth _ Type of filter material__ De th of filter material____./ _ .__:.Total length- ,�d---------------- --__ YP ' / p it: Distance to nearest well--,/(/ - --Distan f rti un tion___/Q-------------Distaefto nearest lot line,�_____ Number of pits-------1_ -Lining mater I______________________ rze: Qiameter_;-�'_�-------------Dept h_-__--•J< __--------------------- U! Cesspool: Distance from nearest well________-_-� ___Distan frory undatian...... -----------Lining material_____________________________________ ❑ Size: Diameter-------------------------'-----------Depth--------------------------------- -----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------__:.,__:___j______________. ------Distance from nearest building--________.___________-______________._. ,�, ❑ Distance to nearest lot'line------------------------------------------------------------ - ----•----------------------------------------------------------------- ------------------------------------------------------ 1 , Remodeling and/or repairing (descriUe) r �U -----•--------------------------- --•----- - ------------------------------------------•---------------------------------------------------------------•-•T----- ---------------------------------------•----------------------------------------•------------------- ---------------------------------- ---- ------- --------------- ---------------- •----------------------------- ----------------------•----------------------------------------- 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 re uiations of the San Joaquin Local Health District. (Signed----'�------- "�' - ------- --------F (Owner and/or Contract By:-----------------------------------------------------------------------------------------------------------------------------------(Title)-------------------------------------------- ------------------- (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 APPLICATION ACCEPTED BY-------------- ----------------- ------------------------------------------------- DATE-----------------------�-- -------------•-------------- REVIEWED BY ---------- DATE ►`' -----•----- BUILDING PERMIT ISSUED------------------- - --11 --------------------------------------------------- ---------------• DATE-----------�/-- -------------------------------------- Alterations and/or recommendations--------- ----------------- ---------- ------------•------------------------•---------------------- ---------------•------------------------------- �^ ' - ----- --------- ---------------------- --------------------------------------------------------------------------------------------------------------------- --------•------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:-.--- `��` ------------------- Date �� 5------------------------------------- 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-4-2M Revised 1.57 F,?.CO.