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APPLICATION FOR SANITATION PERMIT Permit No................ (Complete in Duplicate) JS t pate Issued }- f 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. (� JOB ADDRESS AND LOCATION 1.� U "�_----- `� Vii` (i----- -------'----`--t6ra ------------------------------------- Owner's Name__________________ �J�'v �/ !T - -------------- -- - -----------=------------- Phone Addressr' ----------------------------- ---------- ----------------------------------------------------------------------------------------------•--•--•-------------------------•-•- Contractor's Name--------------qw)Y ----------_- -- ------ Phone----------------------------------- Installation ---- •-------------------_Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __t---- Number of bedrooms _,F---- Number of baths ---I---- Lot size ---- _X--I7r_•---------------------------- Water Supply: Public system [ r Community system ❑ -Private ❑—Depth to Water Table -------- it. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobej$6� lardpan ❑ Previous Application Made: Yes ❑ No IR New Construction: Yes X No ❑ PHA/VA: Yes ❑ Nov TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within_200 feet.) r � Septic Tank: Distance from nearest welL �--------Distance from foundation-__./D__.-------Material---- _______ _ ----------------- [ No. of compartments-----2+---------------Size-_�1S1S-- --- _---Liquid depth----- ----------------Capacity---- ---------- Disposal Field: Distance from nearest well-__X^4--n-Distance-from foundation---1a------ --_.Distance to nearest lot lin e--_.S___ „ Number of lines------- ------ ----------Length of each line--- Width of french__ZYy Type of filter. material__-' -------_---Depth of filter material----/ --------------Total length-___- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____-___-__-_-.-- ❑ Number of pits-------------- ---Lining material-----------------------Size: Diameter-----------------------.Depth----------.---------------------- �J Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- D -------_____-----.---_-- ____-----.❑ Size: Diameter---------------------------- ----------Depth------------------ ------------ --------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------- ---------------------------------------Distance from nearest building-_____-_---------_------_-----.----___-_-. ' ❑ Distance to nearest lot Iine------------------------------------------------------------------------ -------------------- ------------------------------------------------- Remodeli and/or repairing {describe) _____7 �1 -- Q�'-- �ti--- ---- ----------- ------ - ----- ------ ------------------------------------------------------------------------------------------------------------------------------------°--------------------------------------------------------------------- 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. --------------------------------------------------------------------------------------------------(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--.---81-94516-4-------------------------- REVIEWED - -945 - 6--------- REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE---------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------. DATE---------------------"--------------- Alterations and/or recommendations: - ---- ------ ----------- ----------- ----------------------------------------------- ---------------------------------------- -------- . . - _ f1 gg FINAL INSPECTION BY: � �/` ---------------- Date `� d` .`,� �f 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-9-2M . Revised 1.57 FRCO.