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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / UVData Issued 1/5 - a Application is hereby made to the Sar-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 D-LOCATI�OjN, ti Zt Owner's Name--- , , !I�. --------------------- on i --- -- - i Address `7`" !- -- ----- ----'------------------------•------------------------------=--,._--•---------------------------------------------- Contractor's ----•--------- ----------___-----_____-----Contractor's Name--------- ---------------- --------------------------- -----•-------------------------------------------------•-•---- Phone---------------------------------- _ Installation will serve: Residence 1Apartment House ❑ Commercial ❑ Trailer Court ❑ Motpl ❑ Otkgr ❑ Number of living units: - Number of bedrooms _2_- Number of b aths ___ Lot size __ { T _____________________ -,ft.Supply:. Public system. J ommunitY-system El ❑ 'Depth to Water Table ------ Character � of soil to a'tdepth-of 3 feet:; Sand�D Gravel❑ .Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ ,�No New Construction: Yes No ❑ FHA/VA: Yes ❑ '` No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted';# ublic sewer is available within 200 feet.)] �- Tia� Septic nk: Distance from nearest well_____ _____ ___Distance fr �fo lation: Cl�Ma ._________-.____-_-______ ___----_______- No. ofcompartments-------- ---- -----------Size-5 __ -�------------_-.---Liquid FIe�p�t�h-/-,----- -`t Capacity--. ----- Dispos Field: Distance'.from nearest well____y- -__"___?Distance from foundation/O____ .Distance to nearest lot I' _5 Number of lines___________ _ 7j__-.-____'Lengfh'of each line------------lva_Q Width of trench.__ Type of filter materia_ p g ,_--K-De th of filter material_______ Total len th_'_-_______ _ -_-____-___-___ Seepage Pit: Dista ce to near st well------------------------Distance"from foundation___..---------------Disfanc'6 to nearest lot line__-___-_-_-_--_ ❑ Number of pits- ------------------Lining 'material-----------------------Size: Diameter------------- ---- -----Dept h------------------------------ Cesspool: Distance from nearest well___ --- i '_--------T-Distance from foundation--------------------Lining material-------------------------------------. ❑ p p Size: Diameter--- = ------------------------------De th ---- :---------'--Liquid Capacity kgals. N : Priv Distancer rom nearest well____ 4 Distance from nearest buildin i - r ❑ _. . .Distance to nearest lot line-,:;.------- -- •----------------- W . . - =: �. Remodeling and/or repairing (describe)----------------------------------------------------- 4----------------------------------- ----------------------- i r - i.. 4 i \�y i- ----------------------------- ------ ----------------------------------------------------------------------------------------------------------------- ----------------------------- ------------------------ "_______________..___-----_--._--__---_________________-___.___-_.__-_________________________-________________________-_____.._..____________--__-_--__.-____.----________________-_______-..-._-_-_---_-_-__-_________"_-____ I hereby certify that I have prepared this application and that the work will be done:in accordance with-San Joaquin County 1 ordinances, State law and rules and regulations of the San JoWLo'cal +h District. Sined - ---- ------------- _ --- "_ y: ,• 1C• ---- ------------------------------(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 '_ _ DATE--- - -- ----------------------'--------- -- ------ --------------a--- -------- - 5 - ----------------------------------------------- REVIEWED ------------------- -------------- -- REVIEWED BY. --------------- DATE- -` -----------------------------=----------=--- --------------------------------------- BUILDING PERMIT ISSUED--------- =`------------------------------------------------------------------------------ DATE.. r Alterations and/or recommendations--------------------------` '' ---------------•------------------------------------,-------•----•---'a----------------__ ; -----------------•--------••-----•-------•------•--------------; -------------------.-------..--• -------------------- -------------------------------------•------------------------------ --------_ ----------'----------------------------------------------------------------------------------=----------------------------------------------------------------------------------- t i 4 ______________________________________________________--_-_-_____________- ___-_ FINAL INSPECTION BY:_n.,o--=y---•--- ------------ ---------_ " Date v 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-7-2 . Revised 1-57 F,P.CO.