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I APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / 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. , �. / • / JOB ADDRESS AND LOCATION-------,. ,_-- ---_- -_ _�� '- -S "'?'L oI-------------- Owner's Name .�- I - •C.-$s - ------------------- --- -- -- -- ------------ -- Phone Address ----• ----•----- --'-- C°`°« = Contractor's Name------•--=`�_ '�= -� --------------------------------------- ----------------------------------------------- Phone----------------------------------- parfmenf will serve: Residence r Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --�-- Number of bedrooms -_ 'Number of baths __J_,_ Lot size --�,_.'------ Wafer Supply: Public system ❑ Community system Private ---•----------------- ------------ ❑ Depth to Water Table -- ft. •7�e7-C. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam Clay Loam ❑ Clay El Adobe E3 Hardpan ❑ Previous Application Made: Yes ❑ No 5�-- New Construction: Yes [ o ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public_sew.er is available.within 200,feet.) Se tic Tank: Distance from nearest wefl,C,04�_._Distance from foundation_-_i4----------.Material----------------'-- © No. of compartments_---__- ~_ _---___Size-__ - -,}f Liquid depth_---- Capacity- ----- p Capacity { Disposal Field: Distance from nearest well-L47t� -----,Distance from foundation-__,2'/__� -_Distance to nearest not lined�------ ------------ -- Number of lines----- _-__-------_ Length of each line/��_-� d� � Width of trench-. _'----------- Type of filter material--5A_° Depth of filter material--_/--�- length--__ 'Q_'0------------- I - ,r epage Pit: Distance to nearest well------ ---- ----- Distance from foundation--------------------Distance to nearest lot line ------•- Number of pits----------------------Lining material-----------------------Size: Diameter-------_--- - Qeptn_ ----------------- �� 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 { Distance to nearest lot line-_--_-.___________________ --------- 3 --------------------------------------------------------------------- Remodeling --------------Remodeling and/or repairing (descri,beJ_---------------------------------------------------------- r # __-_---------------------------------------------------------- --------------------------------------------------------------------•-__-------_----------------•- - - _-- -----------------„--__- ---- -f 111 -I --------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun1-i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- ----- ---- -- -------------------------- _3 (Owner and/or ContractY�:_ _ Q�.- _ '. - - _:---------- ------=._•_.--- --- ----- __�...,_ _y a _ as __,�_ —(Title)(Pfatplan, showing of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side) FOR D PARTMENT U E ONLY APPLICATION ACCEPTED BY--- ___ __-< ,. ^w"' j { = ---"`'`.. DATE ---�--///5 �--------------------- I REVIEWED BY = ---�------ --------- ---------- - ------ DATE---- --=�----------- --------------------------------------------- UILDING PERMIT ISSUED------------- ---------------------------------------------------r --------- Alterations and/or recommendations:- --------------_---- DATE _ --- -------- ----------------- ------- ----------•--••-- ---------------•----------- --- ----- ---------•----------------------- FINAL INSPECTION:;BY______ ___ ____ __ - .: ate- . ------ -. D SAN JOAQUIN LOCAL HEALTH DISTRICT ' 134 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-