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C {�',1ti1 I� 1`172/ APPLICATION FOR SANITATION PERMIT Permit No. -.R-- 5_.•.______ 9r . (Complete in Duplicate)� � i { P p ) Date Issued -- ------�--�-•�. 11 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 Co my O inanc No. 49. JOB ADDRESS CATION------- ------ Phone _______" ------•------------ - Owner's Name-- ------ ---------------- ------ -- Phone ------ - - -------------------------------•---•- •----•------------------...------- Address------------- -- - --- --- Contractor's Name---- ------- - -:.----- ------ Phone-------------- ---•-----•---------- --------- --- ----------- - 1 Installation will serve: Residence Apartme t House ❑ Commercial ❑ Trailer Court ❑ otel ❑ Other ❑ Number of living units: ..___ u er bedrooms _-Z__ Number of baths _1____ Lot size ___ _--� - - -- I �'L•----------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table -------- ft. I Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 19 New Construction: Yes Ea""No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted 'f ublic sewer is available within 200 feet[) �• �� /�+"" Septic 'ank: Distance from nearest w -I -Distant fro foundation_________ _________Material___I-4Capacit;y-- u --- ____ _---- No. of compartments -------- Size iddepth. ) Dis osal field: Distance from nearest wel_ Dista rom foundation �fl �+"` Distance to nearest lot l,i�]e� ..------_- p Number of lines_________ Length of each line______ ___ _r�_-_.Width of drench_______ "f" _t-- Type of filter materia _ epth of filter materiaL___.___�_ _______Total length_______..-_` ' -_--_�_--�- Seepa e Pit: Distance to nearest well__- f _�_a=IJ`6.ihance from .foundation___.___�_ __._..Distance to nearest lot line_____ Number of pits------J---------------Lining material-64— _ z iometer__-- -- `.M_- -Depth---- -fir__________._------ Cesspool: Distance from nearest well-----------------Distance frl foundation--------------------Lining material_____-_-_-,-________-_______:_____-.-. ❑ Size: Diameter------------------------- -----------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---_------_--------------------------------------Distance from nearest building._________________--________________--- (� ❑ Distance to nearest lot line----------------------------- ----------------- ---------------------•- ---- ------------------------ e-sc�fibe]:_'_= emcelincf and/or repairing .- .. -------------------- -------------- - -�`- ' . -------------------------- ----------------------------- ------ - ---- ------------ ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Joaquin Local Health District. �f�/�` -- -----------------------------------------------------------------(Owner and/or Contractor) (Signed) -------------------- By:-------•-------- --------- - ------------- Title - - --------------------------------------------- - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed-ca.Eeverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTE7DO ---- DATES ------------------ --------------------------------- -• ----- -------------------- - REVIEWEDBY------------------------------- --- ----- -------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED----------------- - ------- DA E---- -----------------------------r-------------••---•- C ------ Alf ations d or recommendatio �— -..�=-- �..__�:r_t__�"�. _ter---- -.tet-----------S.Q.Q.,--- t - ---5-- - - ----------- - ------- - -- -- -------------- - --- •--------- ------- le_QT--- •.S-aA,-Z7.... ------------------------------------lep J Y�'�_�-__.C. .da �•v . .S T 3 i� Fear! 6a,easac; 05 /��- 4[ �k'c/� �A7'' [✓.sly �� S` S"7 ?oc� 0-70)w !�—� �� a 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 E5-9-2M Revised 1.57 F.P.ca-