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M t� 10 �. ry APPLICATION FOR SANITATION PERMIT Permit No. _ _f lYr (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. 544. JOB ADDRESS AND LOCATION...__Z-12ct ----if ------ ---------------------------------------------------------------------------------------------------------------- Owner's Name--- - ---------------------------------------- ------------------ --------------------------------------------- Phone--------------------------------_• Address.......... .91 do Q Contractor's Name-----------_TR� ----yVAd----;r,-R _,She_ 'ivis�------------------------------------------------------ Phone._�q:yFt z 7. _.. Installation will serve: Residence Ek Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms ___I-__ Number of baths ____I__ Lot size __ Q ---/ ____________________________._- Water Supply: Public system ER Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,® Hardpan ❑ Previous Application Made: Yes ❑ No [0 New Construction: Yes ❑ 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-----------------Distance from foundation--------------------Material __----___-_----_-____.-_--___._____--------__-_. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------- ----Capacity------------yr_------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- 0 Number of lines___________________________________Length of each line------------------------------Width of trench-------------____--------. Type of filter material_________________________Depth of filter material-----------------------Total length________________.___.________-__._-_______ Seepage Pit: Distance to nearest well-----NUAK_,�---,Distance from foundation-__../O"______.Distance to nearest lot line__` ® Number of pits--------1------------Lining material_14CA----------Size: Diameter_________!X3±`._--_Dept h__a15 '�__________________ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material--------------------.---_____________ R, ❑ Size: Diameter--------------------------------------Depth. --------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-_------_----_---------------------_-.._. ❑ Distance to nearest lot line----------------------------------------------------------------------- ---------------------------------------------------- --------------- C Remodeling and/or repairing describe - ----------------------------------------- ------------ - -------------------------•-------------------------------------------- ------------------- -------------------------------I----------------------------------------------------------------------------------------------------------------------------:------------------- ---------------------------------------------------------------------------------•-------------------------------------------------------.----------------------------:------------------------- --------- ------------------------ ------------------------------------------------------------------------------------------ -------- ---------------------------- -----•--------------------------------------------- ---------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and ru s and regulations of the an Joaquin Local Health District. / 1 1 Owner and/or Contractor (Signed)---------►== �� = ( / --------------------------- - - By:----------------------- (Title) z�_ ------------------------- (Plot plan, showing size of lot, to i 11 of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- -------------- -- ------------------------------------------------ DATE----------------- ----------------- REVIEWEDBY------------------------------ DATE --�� --- ---- -------------------- BUILDING PERMIT ISSUED------------------------------------ DATE-------------- _ / J -------------------- ------------ ---------------------------------------- Alterations and/or recommendations----------- --------- ---------------------•---------------------------------- ---------- / -------------------------------------------------------------------------------- --- ------------------ -------------------- ---- ------------ a :. -- ---------- ------- ------ ---------------------------------- ---------- --------------- ----•------ -- ------ ------- ------------------------------------------------------------------ j g I O -'--- S / FINAL INSPECTION BY:..-- H----- -- ---- --- -- ------- Date----Z --------- 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 , Revisea 1.57 F.P.CO.