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�y i< 3 L/ `~ Permit No. ........ APPLICATION FOR SANITATION PERMIT (� (Co`mplete in Duplicate) Date G — Date Issued ____ -_.___ Application is hereby-made to the San Joaquin Local Health District for a permit to constr nd i st tl�0 -ork h -rein descri ed. y This application is made in tom c with Coun^y Ordinance No. 549. �� j � 2�- �- S r �j — I 2- OB ADDi�ESS DLO ATIO 1` ------ - --------- Name ------------------ --------------------------- Owner's ------------ :. Phone------------------ -• ---------._.. j -•---- --- -- --- --- ---------- Address .ffJ ---------------------------------------------------•------------------------•-------------------------- ------------- ----� _. Contractor's Name-- ---------------------------------- Phone------•----•-•------•------ - ----•-------------------------------- _ Installation will serve: Residenee�Rpartment House ❑ Commercials❑ ttTrailer'Caurt ❑#Mot l ❑ Other ❑ Number of livingunits: ___ ___ umber of bedrooms ._Z__ Number of baths _1___- Lot size ____ __Oen-X-'- --------- -------------- i I T Water Supply: Public system Community system ❑ -'Private ❑ Depth to Water Table _______'ft." ' ti Character of soil to a depth of.3 feet: Sand ❑ Grave{ F1 Sandy Loam ❑ Clay Loam El Clayk❑ Adobe Hardpan ❑ Previous Application Made: ,Yes ❑ No 2 New Construction: Yes [a No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ( p or cesspool permitted 'f public er is available within 200 feel.} a. f Se tic aokse tic tank x _ p ' ante from nearest we �e Distanced fr, fouacIption/p__.______._ .Mate ic�4___ __________________________ ? r I--- No. of compartments Size __x Liquid �lepi<h- ':Capac�tY _ Dy Dispos field: Distance from nearest wet - dDistance from foundation - Distance to nearest lot line Number of lines-,-------- ______ --Length of each line-___—W- __ Width of trench.___----- -�--�- --- -..- I -- L� Type of filter ma{eri ( - epth of filter material-------:._ ____.___Total lengtht �- � f ' - iz.. . ❑g Number of pits:..__________________Ling Distance from foundation ��"_;.-.__..Distance to nearest lot line-___-________--.- a Lining material -------.------ -----Size: Diameter`=°=' - --------.Depth--------- ---------- See a e Pit:.. Distance to nearest well------7- • I r. . { Cesspool: Distance from nearest well____ ________Distance from foundation------ ❑ Size: Diameter----------- ----- ----Depth----------------=--=--------------------- - - 1-Liquid Capacity---------- •---------------gals. I Privy: Distance from nearest well---------------------- --------------- ----s---Distance from :nearest building----------------------------------- ------ - ❑ Distance to nearest lot line._------- ; ---- --- -- ----- ----- - r--- 3--- Re�odel' g a0d/or r pairing est e) �= '- --------------------------------------------- -:--•--------------------------------- ----------------- -.. a ` .. ------------------------------ I hereby certify that I have prepare9 this applica+ion and that the work will be done in actor - ------ - --------- dance with San Joaquin County ordinances, State laws, and rules regulations of the San Joaquin Local Health District. ' '--.(Owner and/or Contractor) ----------- [Signe �--- -- - -•-- . - #. _-------•---- --- ' (Title] _ -------------------------------- By- 1f ---------•-------------•-•-------------...----- -------------------------------- ----- - (Plot plan, showing size of lot, location'of system in relation to wells, buildings,'etc.,�can be placed1oneverse side]. r FOR DEPARTMENT USE ONLY . APPLICATION ACCEPTED BY' `- Y -- - -- DATE--- ----- :_ -------------------- DATE --l-------- ---------------------------------------- REVIEWEDBY--------------------------- -- --------- - ---------------=----------- BUILDING PERMIT ISSUED------------------------ DATE----------------=---------------- ----------------------- Alterations and/or recommendations---------------------- --------------------------- -----------------------------•-------------------------------•--I----- .. ---------------------------••------•--------•-----------------------._..._--••---------------------•-------------- -------- •---------- ------- ___________________________________ _ _-------------------------------------------------------_---------------- --------------------------------------------------- k _ ----------------------_-------____ • j o FINAL INSPECTION BY:_ _ _ Date_ -- ---------------------- _f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Was+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised 1.57 EP.CO.