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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 7 Date Issued ___ vs U Application is hereby made to the San Joaquin Local Health District for a permit to c nstruct an stall the wor her 'n�escribed. This application is.made.in compliance with County Ordinance No. 549. i •/ � �► JOB ADDRESS AND LOATIONa_ .--� A � "'r' -- f-- - F Owner's Name:- _ _. Phone__`. ------ -------------- ----- Address_ C. [ 3:5".A-------- -------- -----`------•-------------------------------------------------------------------------------- ------- ------- Contractor's Name--8&-,C--- � - - ----- -- -------------------------------------------------------------- Phone --�-- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 19 , Number of living units: __- ____ Number of bedrooms ________ Number of baths -_______ Lot size ____---�`-„ ---- ' Water Supply: Public system ❑ Community system [I Private/y Depth to Water Table ---- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay E-] Adobex Hardpan ❑ t Previous Application Made: Yes ❑ No New Construction: Yes ❑ No V i 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_________________Distance from foundation-----------.--------Material__________-_-_-__-______-_________-.------------- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---------- ------------Capacity--------------I------ Disposal Field: Distance from nearest well-/- __-_Distance from foundation____4---.....Distance to nearest lot line_-112 __- Number of lines-----------/--------------------Length of each line-------&---------�e-----Width of trench.----_- _y_- { -----Total length V47--------------------------- Type of filter material__2--j?oCIC.__Depth of filter material____._-A?---- 9 Seepage Pit: Distance to nearest w// - ell___ _� - _Distance from foun afion___-3 9- - -----.Did an to nearest lot Number of pits--------/- t _Lining material_. _ Size: Diameter------J.6----------Deptn-_-.-___s�_.�______--.-_ -- Cesspool: Distance from nearest well----------------- from foundation-------------------.Lining material----------------------------- ❑ Size: Diameter-------------------------------------Depth--------------------- •----------------------------Liquid Capacity----------------------------ga Privy: Distance from nearest well-------------------------------------------------Distance from nearesr buiiding-----------------------------------------. ❑ Distance to nearest lot line-------- ------------------------------------------------- -----------------•---------------------- - ------------------------ - Remodeling and/or repairing (describe:__ _ .=a!-'-"-k_^- '-'�-- ' ------ . r--------------------------- -----------•---------------------••.--------------`------------------------ -' ---------------'-- -----------------------------------------------------------------------------------'--------...------------------------------------------ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and.regulations of the San Joaquin Local Health District. (Signed) I le}---- - (Orner and/or Contractor) BY:----------------- --------------------•---------------- ----------(Tit (Plot plan, showing size of lot, location ofyste n to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY DATE---- , APPLICATION ACCEPTED BY-------------------------- - -- ---------- ----------------- ------------------ ----- � Z�:--;5- REVIEWED BY------------------------------------------------------ --------------- DATE------. ------------------------------------------ - ------ ---------•------- ------. BUILDING PERMIT ISSUED------------------------------------------------------ ------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:---------------- .-._ ------------------ --------•------------•--•--------------•----------------------------- ' ------•--------------------------------•-••--------- ' -------------•-------•---------------------------------• -------•------------------ .. -----------------------------------------------•-------- ------------------- --------------------------•---------I--------------- ---•---- ------- ---------------------------'-••------------------------------•----------------- ----- FINAL INSPECTION BY:---- #-u ------ Date--------------7�_ 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 FS-9--2M 10-52 Revised W-2100