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APPLICATION FOR SANITATION PERMIT Permit No. ..... &,Y�X,, (Complete in Duplicate) p 3 d Date Issued 6 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein desc 'bed. This application is made in compliance with County Ordinance N 49. ,E JOB ADDRESS AND LOCATIpN_____w_-7 �� ' �_ <. _ f - Owner's Name-------•- ---'�__'�r�=,C' ------------------------------- Phone-------------- •-----------------•-- .� _. ems` _ ��'�-------- - Address------------- 11AIZ,I ee._��__�---------( , --------- .ria . - — - -- - --- --- - Contractor's Name---------- lT / 1�- 'f�. `°'`_- �'t1,114S----- ---•------------- Phone- '140 Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other 11Number of living units: -------- Number of bedrooms -------- Number f b the -_/-- Lot size • A _ Water Supply: Public system ❑ Community system ❑ Privaxyv Depth to Water T ble .r 6 t Character of soil to a depth of 3 feet: Sand Gravel Sam Lo p ❑ ❑ Cla am ay ❑ Adobe�] Hardpan Previous Application Made: Yes ❑ No ❑ New Construction: Yes No FHA/V : Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Se ti Tank: Distance from nearest well---l0?Q-----Distance from foundation-----/0-r____.Materi��_-- �4_f Z(_ No. of compartments_.____,; -_-____- Size_ Dis sal Field: Distance from nearest ell__ __.Distance from foundation-_ �4 -___y____Distance to nearest lot linefj ..... Number of lines___________ __ --------- -Length of each line__r__�'__ _Width of trench__�'�_ y _/------------ • Type of filter material___ _�f>/_Depth of filter material-__., '1___--------Total length______ __(�0 __________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line__-_____________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------ Depth-----------------_______________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________--___________-:__________ ❑ Size: Diameter------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. V Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------._______-_---__-_-_- ❑ Distance to nearest lot line----------------------------------------------------------------•-•--•--------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- --------------------------•--------------------•-------------•------=-----------------------------------------------------------------------•----------------------------- ------------------------------------------------ ---------------------•-------------------------------------•------------------------------------------------------------------------------------------•----------•--------------------------•--•------------------------------ I hereby certify at I have prepar i application and that the work will be done in accordance with San Joaquin County ordinances, State I s and ds and egul ions of the S n Joaquin Local Health District. Ar (Signed) __ -._ __ Owner and/or Contractor BY: (Title) --- ------ (Plot plan, showing size of lot, location of system in relation to wells, bungs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- _ --- ----------------------------------------------- DATE-------t ---------- REVIEWEDBY- -----------------------------------------------------------5� DATE------------ -- --------- ------ --------- BUILDINGPERMIT ISSUED_----------------------------- ------------------------------------------------------------- DATE---------------------------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- -- f*fir) , - - "'----------- , - ----- ------- ` x --------------- ------- - -- - ----------� -. - - ----------------------------- 2 -a -------`= ='`"'- r ----- ------------__--- ---------------- FINALINSPECTION BY----------------------------------------------------------------- Date-------------------------------------- ----------------------- --- 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-9-2M Revised 1.57 F-P.CO-