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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date IssuecV. ___. ` �" --------- 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. ,706 ADDRESS AND LOCATION---------��G/�.�/c.�-------/,��G��------------- --��'�------------- --- ------ -----•-- Owner's Name------ la.�d" �GG f -----r---------------- .....- Phone------------------------------------ Address---------Wi411---------0 -------Pg_r0,C�S� . f� r Contractor's Name--------D_- ------ ----- -------------------------------------------- Ph one Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: T____ Number of bedrooms ___/___ Number of baths __1____ Lot size _______________.___________--_-_-__________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tables ft. Character of soil to a depth of 3 feet: SandGravel ❑ Sandy Loam E] Clay Loam F1Clay E] Adobe ❑ Hardpan_V ❑ Previous Application Made: Yes [] Nox lNew Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public r sewer is available within 200 feet.) f r Se ti Tank: Distance from nearest well_-.,!b-------Distance frgm foundation__,/Q______.__.Material_____� ��__ --------------------- � No. of compartments_.�,�--_-____._._!__Size__ -aec `�Liquid depth__._ _ . Capacity__ Q__s:2_ Disposal Field: Distance from nearest well-_c5i.!------Distance from foundation-/O r__j_____Distance to nearest lot -_---__ Number of lines-___------ 2-___ ___________Length of each line______ZOAQ , �mac[---Width of trench-__..2 I � ------------------ Type of filter material_____ __.Depth of filter material___-��__________._Total length--------/12fd________________________ 4 Seepage Pit: Distance to nearest well----------------------Distance from foundation----.---------------Distance to nearest lot line________________ (ig ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool- Distance from nearest well----------------- from foundation--------------------Lining material_______-.__.__._____._-_---__________ ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. .. Privy: Distance from nearest we]l-_.______ __________________________Distance from nearest building----------------_-____________-____.___._- ❑ Distance to nearest lot line---------------------------------------------------------------------- Remodeling and/or repairing (describe)---- ---------------------------- ----------------•-------------------------•---------- ------ --------------•----------------- •------------------ --------------------------------- -----•----.-------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------- --------------------------------------------------------------------------------•---•----------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- ------------------------------------------------------------=-------------------------------- --------------------------------------------------------------- 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 a egulations of the San Joaquin Local Health District. (Signed) -!� --------------------- ------------------------(Owner @nd/or Contractor) � ------By:. � (Title) s7r _A-M/�� (Plo"lan, showing size-of lot, location of system in relation to wells, buildings, etc., can be placed-on reverse sidej.— FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- -- ----- ------- ---------------------------------------------- REVIEWED ---------------------------------------- DATE XJ REVfEWED BY - - - - -- -- -- -------------------------------- DATE TJX - - BUILDING PERMIT ISSN.IED--------------------------,� ----- --_----------------- ---------------------------- DATE------- ----- Alterations and/or recommendations------------------------- - --------------------- ---------------------------------------------------•--------------------•--------------•------------------- ----------------------------------------------------•---•----------------------------- -----------------------------------------------------------------------------•------------------------------------------------------- - ----------------- ---------------------------------------------------------------------------------------•------------------•--------------------------------------- -----------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---•------------------ ----------------------------------------------- ----------------------------- -------------------------------------------- ------------------------------- ------------------------------------------ FINAL INSPECTION BY:- ��------------ --------- ----------- Date--!.....G .. 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 , Revisep 1-57 F.P.CO.