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Ir r r - APPLICATION FOR SANITATION PERMITPermit No. Xi STS (Complete in Duplicate) V � 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 with County Ordinance No. 549. f/� 17 JOB ADDRESS AND: LOCATION ` ' '�. {-='�"r( .a ' r ,=? '- ''�- .. r Owner's Name �Q .Jn A! C — rt Ph rje ,d ._: .-... -------- -- �J Address d'__ :_ � .-- -- i l---- -- --- ----------------`-----------_----__------ -_F--y--._-.-._-_-.--.-_-_..._ .-__---_-....-._.._.----_......---._-_----.--_.--__.......-....----__---_--_._.--.-__---- Contractor's Name--------------------r --------------------------------•------------ ----------------------------------------------------- Phone----------------------------------- Installation ---...------- -Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑•I Motel ❑ Other;[]p Number of living units: —'Number of bedrooms __-'Number of baths -'— Lot size -----------' Air----------- ------:---�-_-_-------_-- 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 ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No`.W7 New Construction: Yesr No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: �1 ,;,. (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----------------------- Disposal Fiefd: 'Distance from nearest well____ _ ___-Distance from foundation--- ------Distance to nearest lot -[� Number of lines----__----------------------------Length of each line----- Width of trench---S---� v-t..-_------_-- � F 0 Yl Type of filter material_--12.1.1- '-A--Depth of filter material____. �_ __�.r Total length_._---_-:f 2.--�------------------- Seepage Pit: Distance to nearest welt----------------------Distance from foundation..........----------Distance to nearest lot line----_-------_--. ❑ Number of pits----------------------Lining material.----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material- __r_---.-.-_-.---------.-._-__-__-__ ❑ Size: Diameter-------------------------------- ----De Depth------ ---- ----------------------------------- ---Liquid Capacity_-------------------------gals. _ ' -- Privy: Distance from nearest we11---------_---------------------------------------Distance from nearest building.---------------------------------------- [] Distance to nearest lot line----------------------------------------------------------------------------- Remodeiin and/or repairing describe ---------------------------------- K..� 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 PJoaquin Local Health District. Si ned ) --_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-------•-------------- - ---- -- ----'-------------------------------------------------------- DATE----- -----.-...--------------------...-------- ---------- REVIEWEDBY-------------------- ------------------------ -------------- + --- -------------------•-------- DATE-------- BUILDING PERMIT ISSUED----------- ---------------------------- DATE Alterations and/or recommendations:----------------- -------------•--------------------------------------------------------------------------------------•--------------- ----------------------- F _-.._•____••_-.--_..-.._•__-- ._-•_------_--•--------•----------------------------`'--------`----------------------------------------------------------------------------------------------------------------------------- ------------------------------ --- r FINAL INSPECTION BY--------------------- --•----- bate-------- -------•----------1•----•--------------------- ------ - -- 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.