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APPLICATION FOR SANITATION PERMIT Permit No. _/_---_____(J__....... g (Complete in Duplicate) y�1 ,_ _ ._ _ _,_ _ Date Issued J_ Application is hereby made to the San Joaquin Local Health District for a permit to construct anld install the work herein described. This application is made in compliance with County rdi ante No. 549. "'"moi ' JOB ADDRESS A __- ND ,ATION•--- Z Owner's Name--------------- -• __O ------- -- �F t ------ ------ ---------- Phone------------------------- , y-' - Address-------------------•--------------I- -• -----0.4--- J_ - ---------------------•--------•---------•--- ----------- Contractor's Name-----------------Rc_ -----------------------------------.------ Phone- Installation hone Installation will serve: Residence K Apartment House ❑ .Commercial ❑"--Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 3____ Number of bedrooms I____- Number of baths __)----- Lot size _____-_-_-__-____-_ Water Supply: Public'system g Community system..❑ Private F] 'Depth to Water Table � _ ft. 4 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ _Sandy. Loam ❑ Clay Loam 0_ .Clay ❑ Adobe ❑ Hardpan ❑ Previous Application-Made: Yes ❑ No New Construction.:..Yes ❑ tNo g FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_____--_.-________Distance from foundation.---------_......__.Material-_-__--___---.___-_----_-_____________---___- ❑ 4 No. of compartments- --------Size--------------------------------Liquid depth----- :--------------Capacity------------------r--- `' Disposal Field: Dista ce from nearest well__ .Distance from foundation_________.Distance to nearest lot lin ��4'of lines-----------t - Length-'of eac,h''line--- idth of trench -.� �1 -- --------------- Type of filter material_:__ Depth of filter materiaL. ._kt�e._....__Total length______ ___ __ . ._;--_-- Seepage. Distance to nearest well__ _ ____ __ j __ .Distance from �o_undation----�_©____.___.Distance to nearest lot line---,Y--- Number ine_____ ('J Number of pits----------I-----------Lining ma#erial___ _ _f --Size: Diameter__-,3-3:�. Depth__. -V_________________ Cesspool: Distance from nearest well from foundation--------------------Lining material---.-.__-__________________________. ❑ Size: Diameter,---------- `---------------------Depth----------------------------------------------------Liquid Capacity-------------------------._.gals. ` Privy: Distance from nearest well---------------------------------------------------Distancee from nearest building___---__--_____--___-___-__-_-______-. ❑ Distance to nearest lot line------ ------------------------------------------------------------------------------------------------------------ ---------------------- Remodeling and repairing (describe) - --------------------•-•-_---•------------------------- _________________________________________________________________________f_____________-_--_______--_-____________________ ______ -----------------------------------------------------------_-__.__________-______-_-----___________-__--___-_.-_ } L _______________________________________________________________________ _------------------------------------------------------------______-_______-_________-_____--___-____.______________-____________.__--__-___--_______- 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, end r __AYZOnd regulations of the San Joaquin Local Health District. _' I --___ n or Contractor) (Signed) : --------------------------------- - - - - r) 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 r APPLICATION ACCEPTED BY - - - - ---- ! ------- - ------------------------------------------ DATE------------ - 4 - ----------------------------- REVIEWED -----•----------------------REVIEWED BY------------- ----- ' -------------------------------------- DATE---------- ------ BUILDING PERMIT ISSUED---------------------- ---- ------ ------ DATE----- ----------------------------------------------------- Alterations.and/or recommendations:------_-=----------------------------------------------------------------------------------------•----------------------- ----•-----------------•------------- s �---------� �. _ ........._.-A ;----- t a- ----------------------------------•--.------- -- - --------- ----- -------------I--•---•-- -•---------------------------------•---------------------------------- -------------------- FINAL INSPECTIONLEff _ - ------ ------ _ _. Date"-- ------- ......... ----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Arnerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California I. ES-9-2M Revised 1.57 F.P.CO.