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APPLICATION FOR' -SANITATION PERMIT (Complete in Duplicate) Permit No. Date Issued Application is hereby made jo the San Joaquin Local Health.Distr.ict.for a permit to construct and install the work herein described. This applicatiori is made in compliance with County Ordinance No. 549. r , '4- JOB ADDRESS AND = CATION; -------- _-------------- -- ---- :'"t Owner's Name ------ . �` L. d{? Phone. 2 �"- Address-___-- lCl _�-__-- _ ---- ------------------------------------- -- - - - - -- --------- - Contractor's Name------- _r�-----------------------------------_---------------------------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _4_ Number of bedrooms .- Number of baths __/__ 'Lot size _________________.______ Water Supply: Public#system Community system ❑� Private ❑ Depth to Water Table ,?J"ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ i„Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No,0 New Construction: YesX No ❑ FHA/VA: Ye's, ❑ NoX ' f 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-___._______________--.______.___.._____---- N o I of compartments------------- ----------- Size ---------------------------- ---Liquid depth ------------ - -- Capacity ---------------------•- Dispos Field: Distance from. nearest wel!----------------- Distance from foundation -------------------- Distance to nearest -lot line -____-___________ Number of lines ---•_----------- ----------------- Length of each line ------------------------------ offrench -----__-___-__-_--_--------------- _1� Type of filter material ______________________Depth of filter material -----------------------Total length ------------------ ____'__-__'-------_ Seep ge Pit: Distance to nearest elL r -Distance from f 'Fldation_ �__.,-__..Distarrie to -nearest lot line --- - _______ /15f�j Number of pits ___________________Lining material__-Size:,Diam ter_`.- _____.__-_Depth___-_ Cesspool: Distance fro xl nearest well_________________ Distance from foundation --.___..___.Lining material ------------------------ .___________ ❑ Size: Diameter< ----------------------------- Depth ------------ ---------------------------------------Liquid Capacity--- -- -------------------- gals. �e rivy:Distance from nearest well ------------------------------------------------- Distance from nearest building' __________.___________________---_---_--_ ❑ Distance to nearest lot line ----------------------------------------------- --------------------------------------•---------------------------------------- Remodeling and/or repairing (describe):___ v�/-------- -----•---------------------------------------------------11--•---- - - ------=------------------•------------------------------------------------------------------------------------------------------------------------------------ -- 1 hereby certify that I have prepared this appli ation and that the work will be done in accordance with San Joaquin County ordinances, Stafe laws, nd rules d regula ions e n Joaquin Local Health District. (Si ned F 9 )•- --- - -- -- �~ - -- - :- -------=�-------------------------------- - - (Owner and/or Contractor) By: --•--- - ��---------'=---t - ----------•-®------------•-----------------------(Title) (Plot plan s e of lot. I ation of system in relation to wells, buildings, etc., can be placed on revers ide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ----------------------------------- DATE-------------- - APA REVIEWED BY----------x-��----------- �---------------- DATE � r� = BUILDING PERMIT ISSUED ------------------------------- --------------------------------- DATE Alterations and/ -or recommendations-`--------_=------------------------------------------------- -----:-------------x-----------.----------- ----�-.- ----- ---- [---.-------------- -----F-- ---'--'--k-- ---- ------�- ---- ----------- n-P!--------------------- ----------- --- - ----_------------------------------------------- �---------------------- ------------------------------------ ------------------------------------------------------------------------------------------ ---------------_________________________________________________________________--_-___..__.____..._____.__.__._______________._________.___ _ - FINAL INSPECTIONBY:' - C = /p/ -F- �`e e x. Date-- '�� l-�. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California 11 ES -9-2M . Revised 1-57 FY.CO. 300 West Oak Street 132 Sycamore Street 814 North "C” Street Lodi, California Manteca, California Tracy, California r