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APPLICATION FOR SANITATION PERMIT Permit No. _... 3 (Complete in Duplicate) / / 7 Date Issued ------__ _�_:�_/___ Ap"plication 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 LOCATION___.__ _ Owner's Name----_�___ri-4-_n-- '� =----------- Phone --------- -------- -------------------------------- Address----- _ ------------ ---------------------- Contractor's Name---------A-4.77 ..1 Phone----••----------------------------- Installation will serve: Residence ❑ �Apartmeht House ❑ Commercial ❑ Trailer Court @9"Votel E] Other ❑ r: Number of living units: "Number of.bedrooms A? plumber of baths __ __ Lot size i Water Supply: Public system [Community sysfem,❑ Private ❑ Depth to Water Table 4,rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe P-15ardpan ❑ Previous Application Made: Yes ❑ No P yNew!Construction: Yes R*'�No ❑ FHA/VA: Yes ❑ No W?-� 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__-_-___-Distance rom found tion_/.5e-+--__..-__---Mat�al-_-�-•_'-_-_____ _______________ ®� No. of compartrrients-----�-------- ------Size_jZ__X__,-__-__Liquid depth_��;------------Capacify... Q_.. f Disposal Field: Distance from neares well"=:_� ----------.Distance from foundation__________________.Distance to nearest lot/line____,____ Number of lines______---- __ :____'._____ ___Length of each line___:_---_ Width of french.----�Tj_______________ Type of filter material/��_-Depth of filter material____--&--_____Total length------74_---------------- ------- Seepage Pit: Distance to nearest well--_--'y"--__-__----Distance from fou ation__A,0_ _..Dista fe to nearest lot line_ _____ Number of pits_____p-►__________-Lining material Size: Diameter__. _ ___________Deptn___.e�- __________,_ i Cesspool: Distance from nearest well----------------`Distance from foundation-----------.--------Lining material-------------------------------------- 1N ❑ Size. Diameter-------------' �------------Depth---------------------------------- -----------------Liquid Capacity----------------------- ---..gals. Privy: Distance from nearest well------------ _______ __________________________Distance from nearest building-----------------------..----------------- Distance _-__._-___ .-.Distance to nearest lot line--------- ----------------------- - --------- ---------------------- --- --------------;--'----------•----------- -------"---- Remodeling and/or repairing (describe A ---=---------------------------- ------------•-------------- ----------------- ; -------------------- - -- ------- ---------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------•----•----------------.------ 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, nd rules and regulations of the San Joaquin Local Health Disfrict. -------•-•---- (Signed)------------ -- -- -- ----(fir Contractor) By----------------------------------------------- ---- -- ------ &�. ---- -----------------------------------------(Title) = ........ (Plot plan, showing size of lot, locatio f system in relation to wells, buildings, etc., can be placed on reversegide). ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -------------- ---------------------------------------•----------•---------•--- "DATE-E--•----------------------- ---------- ------ ------ REVIEWED BY------------- --------------------- .--------------------•------ ------ ---------------------------------- DATE--- ------------------- - •------- BUILDINGPERMIT ISSUED--------- ----------------------------------------- ----------------------------------- DATE------ ------------------------------------------------ AlterAlterations and/or --- -------•--------- -------/ ations and/or r comma dations f _ = - _ - -4- �- ---•----------------------------------- Z, r~ ------------ ----------- E---f--�' '----- - - ---- - : ------------------------------------ ------ ----------------------- _10 ------ '=------------------- ---------------------- ----------------------- -------------------------------------------------------------- FINAL INSPECTION BY: = = _.- _ - = = Date-----" -------- ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT • 130 South American Street 300 West OakStreet �. ` 132 Sycamore Street ' . 814 North "C" Street Stockton, California Lodi, California Manteca, California k ; Tracy, California ES-9-2M Revised 1.57 FY,CO.