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�,6 y 0" APPLICATION FOR SANITATION PERMIT Permit No/00__'?--Lf --7A (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 County Orrddinance/ No. 549. JOB ADDRESS AND LO ATION, _ ___ __%_0 / �° I 7 (� Owner's Name --------L"- ---------/ l�lef� --------------------------------------- Address------------------------------- _S -AA_vl-- ------------------- •--•---•------- -----------•---------------------------------------------------- --------------- Contractor's Name - = Phone Installation will serve: Residence Ka Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ,c Number of living units: __ Number of bedrooms ___'Number of baths -#-_ Lot size _-_-___/-------------- ` ' _________ _________ _ - - ----------- Water Supply: Public system E] Community system E] Private �epth to Water Table ________ ft. Character of soil to a depth of 3 feet: r Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No w Construction: Yes g?""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 k Distance from nearest well _-------------- D'€stance from foundation -------------------- Material ______--______-_______ ____-_-__-__-___---______- No. of compartments----------- ---- ----- Size -------------------------------- Liquid depth -------------------------- Capacity -------------•--------- Disposal Field: Distance from nearest weltl_ --------bistance from foundation____ 1_a_ ---- .___.Distance to nearest lot line___ ______ Number of lines --------- ___�----_______ Length of each line ------- 3.17 ---------------- Width of trench____,_ `r Type of filter mater ........ Depth of filter material --- /-S-______________Total length ------- 3o_`_____----______-________ 3 Ssepe^Pi'F: Distance to nearest well ---- ----------- Distance from foundation ---- ---------- Distancet nearest lot line_----- - ❑ SCt,+l Number of pits ---) ---------------Lining material__ -'Ys' _._____-_-Size: Diameter_! _ _ 7�j_ _ Depth_________-_--__-_____________ Cesspool: Distance from nearest well ________________Distance from foundation ______________-_.Lining materi__al________-----______-__-___-- -__- 0 ❑ 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) -----------------------------• - — - ----------------------------------------------------------- --•-- ---` --- ---- - _--------------------- -- -----------------------------------------•--------------------------•-----•------------------ ------••-•---•--------•------------- -----------------------------•------------------------ )----•--------•------------------------------------------------------------------------------------- ------------------------------------ T hereby ---- ---------------------- Thereby 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. (Si ned)__x__.__.�f�_----- - _ ____.(Owner and/or Contractor) 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: j`!lv ------VAA.-,Y- ----------------------------------- DATE ------ j;�J_Hj j_ _J__ 1 REVIEWEDBY------------- ------------- r ------ -------------- -------- ---------1_____1 ------- DATE --------------------------------------------------- PERMITISSUED ------------------------------------------------ ----------------------------------------------------- OATE ------------------------------------------- Alterations and/or recom ati s:_.______ - ' ____ __ _.. - - -- ---------- ---------- -- -�� _-- = ---- --- ----------- ----------------------- 1�------ ----;{ r---- -- -- ------------------------------------------ r FINAL INSPECTION BY---------------------- --------- --- -----•----------- Date ------------ ---------------------------- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES -9-2M , Revises 1-57 F,P.CO. 300 West Oak Street 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California