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APPLICATION FOR SANITATION PERMIT Permit No. __.. 3.7.... (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 No. -549. JOB ADDRESS AND LO ATION----ZMAP-1'"-�--------- -------------------------- Owner's Name----------- t------VW------ ---------- ---- ----- Phone.......... .... IVT (P_e----• ' -•------------- -----------•-------- --------- --------. ---------- Address--•--------------------------- -------------------------- Contractor's Name------------------•-•-•-.. ----•- --- --------- Phone.------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: , .__ Number of bedrooms 3-- Number of baths`!__ Lot sizeAt 114a�. - •. Water Supply: Public system ❑ Community system �rivate ❑ Depth to Water Table _ X.24' Character of soil to a depth of 3 feet: Sand❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ardpan❑ Previous Application Made: Yes ❑ No @?0" New Construction: Yes [q"No ❑ FHA/VA: Yes R 'I'No ❑ 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 _eny Distancg from Lfo�/undation___A0---------M trial_-___�rC� _.... No. of compartments------.�.r__- ,.Size._ . x_-i-Q- Liquid depth_ --------------- Capacity___..._ 'o'SG. i Disposal Field: Distance from neare,�j well--&--99 .Distance from foundati .l.f� :Distance to nearest lot line �. Number of lines______.F_____ ___ _ ______ Length of each line____ . ._ "` .. ___ _ Width of trench _1Z� _..._ ..... Type of filter materia _-Depth of filter material---- �� Total length �_,,S Seepage Pit: Distance to nearest well___l� ______Distancero�l�:fiotation_....��._._...Dis arse to nearest lot line. �o� _�► Number of pits----Z-------------Lining materiaVj__ Size: Diameter_, V-------------Depth......2 0.................. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________________________: ❑ Sizer Diameter------------------------ -----------Depth----------------- ---------------------------Liquid Capacity..------------------ ---gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-------------______________•____:_,_____-: ❑ Distance to nearest lot line----- - ---- -- ------ ----- - ----- ------------------- -------•--•---------------------- •--•- -------------- Remodeling and/or repairing (describe):------- ' ----------------------•--------------------•------------•----------------•-----------------------------------------------------------------...................................... --------------•-------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------..•._-.-------•------- I hereby 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 regulatio of the San Joaquin Local Health District. (Signed)......................... -------- - - ----- -------- ------ ------- (Qvatw r Contractor) ley:.................................................. ... -•----. -•••----•---------•--------••••-- ------------------------------------(Title)- ---- - --- s' (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on raver si, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ------------------------------------------------------ DATE .4�;------•-S_tf-----•---•-----•------------- REVIEWEDBY--------------------------------------------•_----------------------------------------------------------------------------- DATE---•--------•-------------................................. BUILDING PERMIT ISSUED-_---------- -------- ----.--------------------------- -__.. DATE_____.-_.._ -_-. Alterations and/or recommendations --------------------- ---------------------- ----------------------- ---------.......................................................... --------------------------------• -------------------- -------------------------•----------------------------------------------------------------------•--------------------•------------------•---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ............................... ----- - e FINAL INSPECTION BY.. --------------------- Date---- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West'Oak Street 132 Sycamore Strut 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 FY.CO.