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APPLICATION FOR SANITATION PERMIT Permit No. ............. (Complete in Duplicate) r7i Date Issued 7__ ____ /_ ...&a v EdA I i DSq -too - o 2 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 AN LOC/A� TION '_" '�- '`�C' ..' -ed `, ------------- 1__ ------•- q '� 1- ------._. Phone---------------------- Owner's Name------. --I---S,l------ Address----------- �y -•------p.� � - Contractor's Name------------- LCL -----�� Q�"--- — Phone?�`:' '-` Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other 91--' Number of living units: _Yr� Number of bedroomsNumber of baths ___ Lot size ___ e-x. d��-r --------------- Water Supply: Public system ❑ Community system ❑ Private ' Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes ❑ No E4--FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wellil�_______Distance from foundation__ ��____..__.Mat al_7------------ _----------------- [t_-� No. of compartments________�----_______Siz e__5Z__X/1'1;, �----.---Liquid Capacity.... _______ � Disposal Field: Distance from nearest welLja .......Distance from foundation__&,O._{-_- ,�_ i]istancce,to nearest lot line_._,3 [y}� Number of lines-------/---------------------- Length.,of,each.]in, -------- ___ .Width of french------ 2_V_1- --------------- Type of filter mater,ial:_ r__ t�Depth of filter material____ _1 _______Total length____________ __ r_ . . ` ... 1 rr fJ-� Seepage Pit: Distance to nearest=welf__A?-_____Distance from foundation____5_V---------Distance to nearest lot [[ �� Number of pits.__._j._7'`---------Lining material_,_ _ _s._:__.Size: Diameter_,3_3_`..........Depth------- _______________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 1771 Size: Diameter--------- I —--;---,-------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearestiwell' -----------------------------_---------Distance from nearest building------------------------------------------ Distance ______._______,________________._-__._.Distance to nearest"lot iine- --------------- -------------------------------------------------- --------- - --------------------------------------------- Remodeling and/or repairing (describe):---- {-- - -- -- - - =--- -_-- f - _--- - __ - ------------ --------- --- - - � ---------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- ---------------------------------------------------------------- ------- - --- ------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, $6-fe laws, and A s and regulations of the n Joaquin Local Health District. ____________________ __ Owner and/or Contractor (Signed)------ -- ----------- ��-� �_ { By----------------- ` -�. (Title)-. ��_ -------------------------------------------- ------ (Plot plan, showing size of lot, loc ion of system in relat/ to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BP--- ------•------------------------------------------------------------------------------- DATF ---------------- REVIEWED BY----------------------- --------------------------------------------------------------------------------- DATE--c=------------------------------------------------------ BUILDING PERMIT ISSUED-_- - - -------------------------------------------------------------------------------- DATE--- UK-- - ------- Alterations and/or recommendation -----------------------------------------------------------------------------------------•------ - --------------- 1 ------------------------=----------• ----------------------------------------------------------------------------------------------------- ------------------------------------- ---------- -----•- ---------- a FINAL INSPECTION BY:--- -- 4----------------------------- Date------.. ---------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Was+ Oak Street 132 Sycamore Street 814 North "C" Street ' Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revisea 1-57 F.P.CO.