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I # " APPLICATION FOR SANITATION PERMIT Permit No. ._,� __��1..... y (Complete in Duplicate) f `rl Date Issued ----1--t------- -- AAI ation is heregy made to the an 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. JOB ADDRESS AND LOCATION.-------- �--3----b-------r !------ ------hv-e.= ----- Owner s Name----------------- _, 1�-' !� d --------------------------- ...... =r' >-------- = = ~='_.c-r-.F Phone------------------------------------ {i Address---------------------------------------------- ----------------------- -------- =------ Contractor's flame - --- --- -- ---- f�"" hone. r Installation will serve- Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ el ❑ Other ❑ } Number of living units: �'____ Number of bedrooms _� Number of baths ___l__ Lot size ----------_-i`}_ __ _____________________ + Water Supply: Public system U/Community system ❑ Private ❑� Depth to Water Table --- ff. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe P-Igardpan ❑ Previous Application Made: Yes [F"* No ❑ New Construction: Yes ❑ No g4-'_FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No sceptic tank or'cesspool permitted if ppuubblicsewer is available within 200 feet.)W s: y Septic T istance from nearest well_________________Distance from fo//uulndation__.�_0____-____-Materia!______�Cd�- _f_ t✓ �" Size_7_-_' Z•-------Liquid edf Rth-----.-F-----------------Capacity...- � r"u' !'d-3'So. of compartments --- - Disposa field: Distance from,nearest well_�'�1v-i4-__Distance from foundation---/4------------Distance to nearest lot line---,S----------- J�\ Number of lines------------L---------- ______Len f`n of each line___-______g '?�-0 ---.Width of trench----- ------- Type of filter material-__�� -----------Depth of filter material_____)- -------------Total length------V-.&----------------------------- Seepage Pit-. 3, Distance to nearest weIL G 1____ .__Distance from foundation----l�-----------Distance to nearest lot line--- 1 Number of pits-_--!----------------Lining material-----V4.tL-------.Size: Diameter---- ............Depth---------i-------------------- 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 line------------------------------------------------ ---------------------- ---------------------------------------------------------------------- Remodeling ----------------------------------------Remodelin and or re airin describe _____________ ________________ ,nt1l. __ `'"�__( !Ld,-_______________of ---------------1d------- -------- -------------------------------------------------------------------------------------•----------------------------------------- :.. ---- --------- y ----------------------------------------------------------- Z - --- ------------- --------- --~�--- ------- ------__ 2---/--------- I hereby certify that Itave.prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules regulations o the San Joaquin Local Health District. (Signed) = --------------------------------------------------------------------------------(Owner and/or Contractor) " ___Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FORPEPARTMENT USE ONLY q APPLICATION ACCEPTE?D BY -----------? V/V '� DATE L �© ------------------------ REVIEWED BY------------------------------- i ` ` -------------------------------'------ ----------------------------------------------------------- DATE_ ---------•----------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------- -------------- Alterations and/or recommendations: J'= -------------•----------------------------------------------------- = .' ---------------------------------------------------------••-•---------------- ------- ----- --------------------------- - ----------- ------ - ------- - '---------- --- - -- - 4 FINAL INSPECTION BY - - - ------- `� Date-------------------------------- 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 4 ES-9-2M , Revised 1.57 F.P.CO.