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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. _ T r JOB ADDRESS AND LOCATION 3i'-a �--------5 YY ( -- -- i .-K�Owner's Name------------A --�4--- ------------------------------- 2----------------(-�---------------------- -_-_ Phone-Y-0 hone-Y-0----- Address-------------------------- ---- GI ; - � Yyw/ b---- �� - Contractor's Name---- ----------------------- ---------------------------------------------------------------------------------- Phone----------------------------------- 15J Installation will serve: Residence E3" Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Q Number of livingunits: �______ Number of bedrooms ._�____ Number of baths __l__.. Lot size __�'l__X_�9Q_______________.__.__._._._.._._ U 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[2]"6Iay.Loam I-] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes No pp ❑ [0�-'_New Construction: Yes 0--No ❑ FHA/VA: Yes ❑ No �� G TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well7h -_-Dist ce from foundation__.��__----------Mat ial___.L No. of com artments--.---� _---SizeX_s_�`_ Liquid depth ___________Capacity p y q R _ Disposal Field: Distance from nearest well V1-�:.._Distance from foundatio ._.... istance to nearest lot line---S../------- Number -_-._- Number of lines_____________ __________________Length of each line/-P' .� Width of trench-__2_Y-``-_______-__________ Type of filter material---I�_-cL.�---------._Depth of filter material-----19._`_..........Total length------(&0-____________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation___-__..-_-_--___-_.Distance to nearest lot line---- O ElNumber of pits----------------------Lining material-----------------------Size: Diameter____--_-_--_-_-.-----Depth_.------------------.___________. c Cesspool: Distance from nearest well-- _-_-__---_-_Distance from foundation--------------------Lining material---.--_------------------------____ G ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity.---------------------------gals. Priv Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------- ' Remodeling and/or repairing (describe): w�Q �,~�aA%"' ----------- ----------------------------------------- -----------------------=----------------------------------- ---------------------•-•-------------------------=-----------------•----------------------------------------------- (A ---------------------------------------•-------------------•--------------•-----------------------------------------------------------------------------------------------.--------------------------------------------------- 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 ;oaqui Deal Health District. (Signed)-X------------------- r ------- ----- --- ----- ---------------------------------------------(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). FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY----- D— ----- --------------------------------------- DATE------I Q - 15 REVIEWEDBY--------------------------------------------- ---------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------.. DATE------------------------------------------------------------ Alterations and/or recommendations---------------------------------------- ---------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- --------- ------------------------------------------------------------------------------------------------------------------------------------- -------------------------- --------------------------------- ------------------------------------------------------•-------------------------------------•-----•--------•--------------------------- ---------- - _ AL INSPECTION BY:.------------------•------------------- -. Date------Xd ------------------------- -----------------------•---------- 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 1.57 F.P.CO.