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ti�15� ✓ �6 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ___ 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 CountyOrdinance No. 549. JOB ADDRESS AND LOCATION-- -�--g_ �I�_-fJd Owner's Name--�-----r�-i JL.4,_,n -- -------------------••----------------------- - ----------------------------- ---- Phone � ,5 Address7�d Ax.►---- P a Contractor's Name------ - mv---- - --- --�- -- - -------------------------------------------- Phone S—Z 7� - F Installation will serve: Residence ® Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_.1___ Number of bedrooms __/---- Number of baths ----I_ Lot size _____ ---------------------------------- Water -------------------------------- Water Supply: Public system @( Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe( Hardpan ❑ Previous Application Made: Yes ❑ No [4 New Construction: Yes RS No ❑ 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 well /l��1 ----Distance from foundation__/_1v--_!__-_____-Material____TQ-.(- j.--------__ No, of compartments------ ------ ----- __Size-----2K47X_7-----_---Liquid depth------ ..................Capacity.-k14 �_4r Disposal Field: Distance from nearest well �0-0+ ___Distance from foundation__16_-r -__-_Distance to nearest lot line_* _--._____- Number of lines--------------------/_- -J-----Length of each line------------------_----------Width of trench-------A�K_0-------------•-- p Type of -Filter material_____�_� _a ---Depth of filter material-----/--'•__---------Total length-------------��__f---____------------ M Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line_-----___________ ❑ Number of pits----------------------Lining material-----_-----------------Size: Diameter----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation_-------------------Lining material_------__.____._____._______________. ❑ Size. Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity--------------------- gals. Privy: Distance from nearest we€I-------------------------------------------------Distance from nearest building------ ___..______------_-_-_-____.______- ' ❑ Distance to nearest lot line Remodeling and/or repairing (describe= (/ ... N t --------------------------------------------------------•-•---------'---------•------------- ---------------------------•-----•-----------•---------......-------------------•--------••-•------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 J aquin Local Health District. t/ {Owner and/or(Signed)--------- --- ------ -- ----------------------------------- --------------------------- / Contractor) By:------------------------------------------------------------------ ----- -------------------------- --------------(Title)----------Q --_tA-- - -- ----------------------------- [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse si e}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ----------- - --------- -- ---- --------------------------------- DATE----------------•---------- REVIEWED BY------------------------------------- ----------- --------- ---------- - - - - ------- ----------------------- DATE----- i BUILDING PERMIT ISSUED------_----------------- 4 - , --- -- ------------------------ DATE-------I------------•----------- -- ----------------- -- Alterationsand/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------•-•------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -•------------------------------------------ -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------I-------------------------------------------------- ---- ---------------------------------------------------- --------------------------------------------------------------------------------- FINAL INSPECTION BY:- ---- f_-•- -- - ----------•------- -------- 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 i + ES-9-2M Revised 1-57 F.P.00.