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1APPLICATION FOR SANITATION 1 PERMIT Permit No. (Complete in Duplicated 7141-5 1 pate Issued --- ___ �7- - 1� 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. JOBADDRESS AND LOCATION.- a �V a .-----_ 4' ---------------•--------------------------------------------------------------------------------- f ----------------- Phone----• ------------------------------ Owner's Name-------------------- - -- ---- �.>r'-��-�`--�--�-----F--------------•-------- ----------------------------------- Address----------••------------- -------------- ------------ ------ -------•-------------------------• ---------------------------------------...---- Contractor's Name-- 5s � / 1� __ �r I ' P#�one 1/ �_ Installation will serve: Res-idence)4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ________ Number of bedrooms Z.- Number of baths I--- Lot size --- ---- 6-------�-�-- -40---------------------- Water Supply: Public systernX Community system ❑ Private ❑ Depth to Water Table r. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob o Hardpan ❑ Previous Application Made: Yes P� No >( New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: F (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) , Septic lanL Distance from nearest well-----------------Distance from foundation-------------------.Material-__---_-___________-_________________________-- [ No. of compartments______________ -----------Size--------------------------------Liquid depth--------------------- ----Capacity----------------------- _ Disposal Field: Distance from nearest eh__— ___Distance from foundation-------`------Distance to nearest lot line----2_ __- --'� Number o$ lines__________ __ __-_,Length of each line-------- of trench....Se---_________________ Type of filter materia__I r__Depth of filter material___ __________Total length_________ _ _______________________ Seepage Pit: Distance;to nearest well____��'.___------Distance fr f ndation___ __ ______.Deistance to nearest lot line---1Q_______ XNumber of pits------- Lining material . _ _ _Size: Diameter____-- Depth------ ---------------- Cesspool: Distance from'nearest well-----------------Distanc ro f ndation---._._____-____.Lining material--------------------- ❑ Size: Diameter------ ------------------------------- Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------- ___________________________________Distance from nearest building------.-------------------_.._ I ❑ Distance to nearest lot line-------------------------- --- ----------------------- ------------ ----------- ---- ----------------------------- ---------- Remodeling rep g (describe):-------- E -----• -------- -=- - ---------------------------------- ------------------------------------ l ---- .------- ---------------------------------------------::--------------------------------------- -----------:::::----------------------::::------------------------------:_--------------------------------------------------- ----------JI hereby certify that I 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. (Signed) --------(Owner and/or Contractor) BY---------" --------------------------------------------------(Title)--------------------------------------------- ------------------ (Plot plan, showin :size of lot. I cats in of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ------------------ DATE "° �z i REVIEWED BY------------------------------------ ------ DATE.---7:�V ------ - PERMIT ISSUED F ------- DATE --- – ----------- k ^ Alterationsand/or recommendations------------- ------------------------------------------------------•---------------•------•-------------•-•--.-......----------------------------------•--- F i -'----------------- ------ - ----------- ----' ---------- - - ----------------- --------------------------------------- --- FINAL INSPECTION BY:---- __ ----------- Date_ .�_�.-�-___��--.1------ -- ------------------------------- - ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Stree+ 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Reviseq 1.57 F.P.CO.