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IXIY nn� 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 County Ordinance N . 549. V JOB AbDRESS A OCATION. ---7�-- _ _ g Owner's Name -,----'------•� ----------- ------------- Pnone -- `__- F Address- •-- -- ' ' - ..--- ----•------------------------ Contractor's Name-------------- Gtr'_ G -- )�'�/----------------------------------------------- Phone �-r.--- � Installation will serve: Residence [-9partment House ❑ Commercial [❑ Trailer Court E] Motel ❑ Other ❑ ._ Number of baths _� ! �_ Number of living units: _�__ Number of bedrooms - ____ Lot size __ __ _____ __________._ ____.__ ___-_-________.____ 4 Water Supply: Public system 2--6ommunity system'❑ .Private ❑ Depth to Water Table Character of soil to a depth of 3 fee+ Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Con s+ruction:"Yes.❑ No [E�IFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 fee+.) Se tic Tank: Distance from nearest well-----------------Distance from foundation----C-------------- Material________-___-.__._____._ No. of compartmems--------------------------Size---------------------------.---Liquid depth--------- - - Capacity----------------------- is I Field: Distance from nearest well_________________Distance from foundation Distance to nearest lot line----------------- ' Number of lines-------------------------------t'` ength of each line-----------------------------Width of french----------------------------------- Type of filter material------__________"._7-Depth of filter materia----------------------- length____________________.__________---_____-- Seepage it: Distance to nearest well__ _ _ ___________Distanc m f undation_Lp_____._..Dista Distance to nearest lot Fine_-l---_____ Number of Pits__•'j------_-____Lining material_ _ __.Size: Diameter__0.13_.____.___ Dept th I 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_________._____________.________-_____._. E ❑ Distance to nearest lot line-------------------------- ------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe: --------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I I ------ -------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S a law and r and'regui tions of the San Joaquin Local Health District. (Signed)___ _(Owner and/or Contractor) By:.-----•--•------------- ---- -- ------`-- = (Title} (Plot plan, showing size of lot, location 'of system in .relation ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- -------------------=-- -- ---- ------------------------------------------------ DATE -------- REVIEWEDBY-------------------------------------- -------------------------------------------------- DATE-------- BUILDINGPERMIT ISSUED----------------f------------- - - ------------------------------------------------ DATE-------- --------------------------------------------- Alterationsand/or recommendations:-------- - -- ---- --------------------------------------------------------------------------------. •-------- --------•--------------------------- -----------------•------------•-----------------------•--------------- ---- -------------------- -------------- - - ---.---•- --•------- - -- - FINAL INSPECTION BY------ -- --- =-------------- -------- -------------------- Date------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oak Street 132 Sycamore. Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M - Revised 1-.57 FY.CO.