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- _ ---- to b, APPLICATION FOR SANITATION PERMIT Permit No. .. -- --------------•------------- ------------------- ------- (Complete in Duplicate) This Permit-Expires 1 Year From Date Issued 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. r = k JOB ADDRESS AND LOCATION' :. a 1 - ----------•--------------------------- Owner's Name - � ----- ----------------- ------ Phone--..---------.--_------- t S-L• Address----------_-•--------------- 1-57 -6 � " '"1g �,e-------------------------------------------------------------------------- Contractor's Name----------------------- _.-.. !_.G� i------------------ -------- -------------- Phone.--,q Installation will serve: Residence ~ Apartment House ❑ Commercial j] Trailer Court ❑ Motel ❑ Other ❑ f' Number of living units: -_ _-. Number of bedrooms .2— Number of.baths ./-.--- Lot size ._-" Water Supply: Public:ssystem Communi#y system'[] Private ❑ Depth to Water Tablet. Character of soil to a depth of 3 feet: •Sand.❑ Gravel ❑ Sandy Loam❑ Ciay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,date________ __________) No f. New Constru cfion::Yes ❑ No © FHA/VA: Yes ❑ No-E� TYPE OF INSTALLATION AND SPECIFICATIONS:— �^ ' (No septic tank or cesspool permitted if public sewer is available within 200 feet. Septic Tia k: Distance from nearest well-----N-"-___-Distance from foundation + ---------Material""-.___ o. o compartments ----------Size----------------------=---------Liquid depth------------------------ Capacity"... t ' Disposal Fi d: Distance from nearest well____>C___ -Distance from foundation_---..,-6 f Distance to nearest lot p Number of lines------'-_�-------------------------,Length- of each line------_-- -- - 1� ----- �r ��------------.Width of trench----•-t�-l�-�----------------•--- 1/� ------ Type of filter material_ rF 1 yp 3-sa_�- -"------Depth of filter material---- -------------Total length------- �'.._•---------------------.- Seepage Pit: Distance to nearest well___""><___--____Distance from foundation-----/.p_-_/-----.Distance to nearest lot [jam Number of pits_-_----�- --------- -material._ Qs~_k------Size: Diameter._._,3 . `-- ' Depth ED'S ----------------- Cesspool: Distance from nearest well--- ----------Distance from foundation------------------..Lining material,_---._ Size: Diameter-------------------------------------- --------- - ---------------Depth_----------.-----------•-•------- -----------Liquid Capacity-----------------------. gals. \ . f Privy: Distance from nearest { well----....."": " Dista_"__""----__"""-.". _ :_ nce from nearest building ------------------------------------ Drstarce to nearest lot line-----"----------------- ,- .- __-_ --- -f -- - Remodeling and/or repairing (describe):-.___"--""--_"".__.__----__'-- y�! ° f f ----- -------------------------------------- ----------------- '"_, -- . I ---- ' --------_------- -'------------------- ----------------- I;here6y certify that I have prepared this application and-fhat the work will be done in accordance with San Joaquin County ordinances, State laws.'.AQd rules and k --- -- --7ulatios. of.theF`.Sa n'%Joaq" u�in',LoNc�al..Healf.hrr.".D.-i,-s-tyr,.i.cF t. f (Signed)------------------ ----- --- - -- - _ � _ (Owner and/or Contractor) BY ---------- ---- -----/_r__"- ------------------ (Plot plan, showing size I , location of system in relation to wells, builOF, ,fc., can be placed on reverse side. �. FOR DEPARTME T USE ONLY 57 fDATE--- REVIEWED �PPLICATION ACCEPTED BY___ -=- ��- -= -----�.L_��-"---- -.= - DATE--- IWED BY-----------------•------------ =------"- . ------------------------------------------------------------- DATE-- BUILDING PERMIT ISSUED-------------------------------------------------------------r DATE------"-- _ Alterations and/or recommendations:. ---------------- -------------•--------- -------------------•----------------- --- ----------•---------------------- ----------------------- -------------------- --------------------- -------------------..------------------------------------------------------ . . . ., .,. FINAL INSPECTION "BY:..__"'..:. " _�-� _ --Date= y "..7 / SAN `JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street + 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REV19Eo B-59 F.P.co.SM 6-Eo I