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^ r 1 / �__PK APPLICATION FOR`SANITATION PERMIT Permit No. -.A!-L-�O-a_.-... (Complete in Duplicate) Date Issued __0----- Application is hereb' made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application,is 2de in compliance with County Ordinance No. 49.j ' a JOB ADDRESS A LOCATION._ , _ _ =_ --_- ----- dwner s Name-- - -- ;.. r - ---_ -------------- Phone ---'' -'. � t a Contractor's 'Name '-R---- - ---------`------------- Phone � 2� - ' Installation will serve: Residence'K .A artment-House ❑. Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ;_/.__ Nu`mber of beclroorris 4`- Number of'baths --/--- Lot size -------�4>CISO-__-_-_____-•_-_--_.__ Water Supply: Public system Community system ❑ .Private ❑ Depth to Water Table llf_ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe* Hardpan ❑ Previous Application Made: Yes E] No� New Construction: Yes No E] FHA/VA: Yes E' ] No,� TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or'cesspool perrrtiffed if public sewer is available within 200 feet.) y Diiance from nearest Septic Tank: Not of compartments---weIL--------- -------Sizeance from foundatiLiquid depth-,.Material --------Capacity------------------------ ' Dispo Field: Distance from nearest well ---------------- Distance from foundation---------------------Distance to nearest lot line----------------- Number ------- ------Number of lines-----------------------------------Length of each line-----------------'--------- .Width of french Type of filter material-------------------------Depth of-filter material--_-------------------:-Total length---------------------- -------------------- Seepage Pit: Distance to nearest well _---___Disfance from undation--,1��4"4Distance to nearest lot line--rY"74-__ Number of pits----- `--------:__ m Lining aterial A-----.Size: Diameter_- _ ....... . Depth___v��:. Cesspool: Distance from nearest well----------------Distance from foundation------------------�'Lining material-----__---------_ ❑ Size: Diameter-------- -----------------------------Depth------------------------------------------ �_ :lLiquid Capacity----------------------------gals. Privy: Distance from nearest well-----------.--------------------------------------Distance from Inearest building-------- _------__-----. El to nearest loft line--------------- -------------------- --------------•---•----------- Remodeli or repairing (describe):_.---_- ., --- _- _ __ -- --------- ------------- ---------------------•--- ---- --=-------•-----------------------•---•------------- --- i . = .f ----------------------• ----------------------------------•--------------------------------------••------ ------------------------------ 11 t I hereby cerfify that,l have prepared this application and that the work will-be donesin accordance with San Joaquin County ordinances, State law , d rul s a regulati ns the S Joaqui n Local Health District. (Signed)-- ; - -- ------- - ------ ------------------------------ -----------------(Owne nd/or Contractor) ..Y By:. ....... --- • --- -- - ----- -----------------------------------=-=---------------------(Title. - -------------- --------- (Plot plan s e of lot, c tion of system in relation to wells, buildings, etc., can be.p ced on rev a side). FOR DEPARTMENT USE ONLY I 1 APPLICATION ACCEPTED BY ..-..-�� 2:r' =---- ----- ---- --------------------------------------- DATE----.,,?Z.-,-e�f°`4..11------------ •-------•------- �. REVIEWED BY-------------------------------------- - = -------------------- DATE ------------ -- BUILDING PERMIT ISSUED --------------- ---------------• DATE t Alterations and/or recommendafion$Z = ---' - -- --- :��----------- -----------••--------- �- ----------------------- --------------------- -------•----------- k FINAL INSPECTION BY;._ a _ - . ` ? r � �-=-----= 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 i -ES-9-2M . Revised 1.57 EP.CO.