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1 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate} 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. 4�4 JOB ADDRESS AND LOCATION �. i�'Ic- ------------------------------------------ Y4 ------fir - --------------- .� /r' _ r g Owner's Namex- — ----------•----------------• Phone d 1 Cf -; Address-- /- - -- a r �' { Contractor's Name--------------------------------------------------------------------------------------------------------------------------------- ------ Phone----------------------------------- Installation will serve: Residence P•f Aparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑] Number of livingunits: -----__- Number of bedrooms _ Lot size ° C �-- Number of baths C 1,1-�-1�.-�---�-----�'-" ----------------- Water Supply: Public system ❑ Community system ❑ Private [?PDepth to Water Table eft. 4ze) Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [21-10ay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No 'New Construction: Yes ❑ No E�--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 wellsd______Distan from foundafion___f_��_--__. _.Mater- I_ E ' '/ Pr No. of compartments.._--___ Size_____ _____�zX. F_Liquid depth_______ K+ "____Capacity____�_�'� Disposal Field: Distance from nearest well__/;.5.�.__Distance from foundation-_ --_w_.____..Distance to nearest lot line______ ____ -' Number of lines______________ Length of each line________�r_ --------------Width of french-------- ` ------------- Type ._______ Type of filter material__ __ _Depth of filter material--------/tr--_______Total length--------------__��__---��—_e_------j__-- �� Seepage Pit: Distance to nearest well-_ ____._------Distance fr m feu dation---e� G__. -------Distance to nearest lot line_'_f -_-_._ Number of pits____________________Lining material .Size: Diameter �r Depth_____ ,Q__ 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 1ine-------------------------------------------- ----------------------- ------------- Remodeling -----------------•--- rRemodeling a d or repairing {describe)------------------------------------------------ ------------ ----------••--------- --•------------------• -- ------- ----------�' ° --�4--------------------------- ---�-,.,�-.---- -------------------------- ------------------------a---l--------- ;-- - ' ' ------------------ •------------------------- ----------- ------------ ----------- `- � I hereby certify that I have prepared this application and that the work will be done in acc rdance with San Joaquin County ordinances, State laws, and rules and regulations,of the San Joaquin Local Health District. (Signed)------------------r--- _ --------------------- --------------------------------------(Owner and/or Contractor) - -------- BY= •' -^''�' -----------------------------Title `:- ` "'---------- (Plot plan, showing size of lot, location ?ystem in relation to wells, buildings, etc., can be placed on reverse side). 6s } v / FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------- --- -- ---- ------ DATE------- ---------- ------------- ----------- --- REVIEWED BY------------------------------------ - - _ DATE----------------------------- ------�----------------- BUILDING PERMIT ISSUED---------------------------------------- ------------------------------------------------- DATE----- Alterations and/or recommendations:------------------------ --- --------------------------------------------------------------•----•----------------•-•--------------------------•------------- ------------------------------------------------------------------------------ / ---------- --------------------- ------------------------------------------------ --------------------------------- -- --------------------------------------------------------------- a0 y " -- -� --------------------------------------------------------- FINAL INSPECTION BY r �� ------------- � - Date----�- -- --�j 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 LS-9-2M Revises 1.57 F.P,CO.