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�s1 \\, ,,N APPLICATION FOR SANITATION PERMIT Permit No. ____�._,�__�j_.G/ _�. A (Complete in Duplicate) 6 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 County Ordinance No, 549. JOB ADDRESS AND LOCA ONT ----------------•------------------------------------- Owner's Name_e44..:J 1(-- Address -•-J��c•- _07�----------- --- -------------------------------------------------------------------- .......... Contractor's Name--- - ---- ---- _4 ----- - I -------•-------- Phone----------------------------------- Installation ----------- •---- - Installation will serve: Reside ce tN A artment House�mmercial Trailer Court Mot p ❑ ❑ ❑ el ❑ Other ❑ Number of living units: _____I Number of bedrooms __2._ Number of baths __1---- Lot size _____ 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 ❑ Clay ❑ Adobeg Hardpan ❑ Previous Application Made: Yes ❑ No VL New Construction- Yes X No ❑ FHA/VA: Yes ❑ No X 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__ &Q__Dista�nxcp fro fou dation----- D__f___-.MaterialR-jo -C a }'„-__-_- (� No, of compartments---------;2—________ _Size------ =dation ------Liquid depth--------s�"_�_.____-___Capacity-----Qp _y a_ Disposal Fiefd: Distance from nearest well___+ ✓ .._Distance ____tQ_'_-_._____.Distance to nearest lot line-- Number of lines---------?-----------------------Length of each --------------Width of trench------ Y-`------------------ Type of filter material___-'ReG/<--------Depth of filter mate ria l____��_- .---_--_____Total length____ ~P--------.-__ ----------------- Seepage Pit: Distance to nearest well__- s_n. ______Distance from foyndation---�Q_----------Distance to nearest lot line__14 �3 p g ' 4--- ---------3 ----Depth_ Z'I--------------------- Cesspool: of its____._1 __------__Linin material______ _ :��_ Size: Diameter______.. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__._______.._____--.____-------------� ❑ Size: Diameter----- ---------------------------------Depth----------------------------------------------------Liquid Capacity------------ gals. Privy: Distance from nearest well---------------------------_---------------------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 and regulations of the San Joaquin Local Health District. - � yy t (Signed--------- = ` - -----x - -- -----------------(Owner and/or Contractor) t 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-------------------------------- b---- ---------------------------------------- DATE_------ . REVIEWEDBY-------------------------------- ---------------------------- ---------------------------------------------------------- DATE--------------1 BUILDING PERMIT ISSUED--------------------------------------- -- ---- - DATE------------- - ---------- -------------------------------------- ----- - ------------ ---------------------- Alterations and/or recommendations:---------- ---------------------- - ------------- --------------------------------- -------------- -•------------ ------------------ r --------- --------------------- - ----- -•- ----------------------------------- ------------------------------------------------------ /C _ fig --------------------------------------------------- ---------------- -- -- FINAL INSPECTION BY:-------Z4,0_4--------------------- ------ Date- ------L--- --- '+--`. 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 . Rev;sea 1-57 F.P CO.