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APPLICATION FOR SANITATION PERMIT Permit No. j 7 (Complete in Duplicate) 3l pDate 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 F �Y _ a , - _ ` ----------------------- JOB ADDRESS AND LOCATION----(_� ___�2 -? _._____ _-_-------- Owners Name - L Phone �:L f =s - (t1 i^^,'. ------- --------------- -------------------------------------------------------- Address----- --- •------------------------- _ --------- - ------------------------------------------------------- `---• Qi� tel°. r ------------------------------------------- Phone----=-------------- Contractor's Name--------------•------------- _-•-•�"-------�----�----- �', ----•---------• Installation will serve: Residence D-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ - -_- Number of bedrooms 2✓____ Number of baths J.__ Lot size ____��^'4_°!�-!_ �____________________ Water Supply: Public system [��Community system ❑ Private ❑ Depth to Water Table _'______ ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑-"THardpan ❑ Previous Application Made: Yes ❑ No 2- New Construction: Yes O"No ❑ FHA/VA: Yes ❑ No j�— �, 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_N�X4n___Distance from,foundation---/ '-----------Material____l.0 �A------------------------------- No. -______f_________- ®/ No. of compartments---. --------------S:ze__ _y_ -_.V�i-,-_Liquid depth----- ---_____---_-----Capacity---___. -------- Disposal Field: Distance from neares well R "'� __.Distance from fou f- n_.t_�`'_............Distance to nearest lot Line-_�-_�______ 16 ®� Number of IinEs________ Length of..each {i ----^-��+•idth of trench-_ Y______________'___ Type of filter materia____ORt. '-_______Depth of filter material___ - ____/____Total length_- Q-_�_____- See pa ePit: Distance to nearest well___!y ---Distance f fo ndation______!.v____._..Distance to nearest lot lie____ ______ [, Number.of pits--------1------------Lining material----__ _Size: Diameter____�7,3___-------- .Depth....Z. -_-_________________ Cesspool: Distance from nearest well________________Distance from foundation------------------- Lining material_______..__--------.____..._____.___. ❑ Size: Diameter---------------------------- ---------Depth-=------------------------------------------------Liquid Capacity ---------------------------gals. Privy:. Distance from nearest well-----------------------------------=-------------Distance from nearest building------------------------------------------ ElDistance to nearest lot hrib----------------------------------------------------------------------- ------ ------------------------------------------------------- 'Remodeling and/or repairing (describe):---------------------------------------------------------------•-------------------------------- -------------------------------------------------------- --------------- ------------------------------------- -------------------------------------------------•---••------------------------------------------------------------------------------------•-------------------------------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Si ned --if es/ f`== J = ----------------------------------------------------------`'(Owner and/or Contractor1 (Sig �---- -•-=--- By:-------------------------------------------------------------------------------------------------------------------------------------{Title)-------------------------------------------------- F (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 APPLICATION ACCEPTED BY----------------- --------------------- ------------------------ --------------- DATE-----= --------------------------- REVIEWEDBY----------------------------------------------------------= --------------------- ---------------- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------ --------- DATE------------------------------------------------------------- Alterationsand/or recommendations-----------------------------------------------------------------------------------------------•--------------•----------------------------------------•------- --------------------------•----•------•------------------------- -------------------------- ---------------------------•---------------------------------------•---• -•---•-•--••---------------------•--•---•----------- --------------------------------------------------------•------•-------- -------------------------------------------------------------------------------------------------•-----------------------------•--------------- -----•--------------------------------------------------------------------- --------------- --------------------------------------•------------------------------------------------------------------------------------.--- -------------------------------- -------------------------------•------ ----------------------------------------------------------------------------------------------- FINAL INSPECTION BY:---- -------------------------- Date--------�!-------pe ------ { -----------------------•---- 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 Revisea 1.57 F-P.CO.