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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) lP �-y Date issued __ _L___ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he e' described. This application is made in compliance with County Ordinance No. 549, 0��'!20�JS JUu ^UDRESS AN LOCATJON- .�. -. i..s�G iz' 'Q a'��-rw,.�.�,•� f '--------- - -------- - 11 9 Owner's Name__ - -------------------------------------------- �"� Z / --------------- Phone- -- ------------------------- Address----------- ��•----- Contractor's Name_�i '�'_*__A ------------------------------------------------------------------ ---------------------------------------------- Phone----------------------------------- t/1j Installation will serve: Residence PX1 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: Number of bedrooms __fir_. Number of baths 1� _ Lot size ___I_��r_� '_ � Water Supply: Public system ❑ Community system E] Private PP Depth to Water Table �_ ft. - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam k Clay Loam ❑ Clay [❑ Adobe ❑ Hardpan ❑ ,I Previous Application Made: Yes ❑ No 1� New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ VJ 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--v;rQ-------Distance from foundation-- -�_V---------Material_ ----------------------- Q I� No. of compartments_.----s�._--------------Size_ _4.8 _4------.---Liquid depa h___�_----------------Capacity_��"I-�_.___ Disposal Field: Distance from nearest well---S_U_____ _Distance from foundation--- .___________Distance to nearest lot line__•Sv_______. Number of Eines____bZ.______________��jj Length of each line---_Q a___________________Width of trench__ ` Type of filter material __�._�l�s.�--Depth of filter material__.�4�y------___Total length----/_ -a_________________________ 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. Privy: Distance from nearest well____________________________ _-____.._Distance from nearest buiiding__--____________________.__-______.__._. ❑ Distance to nearest lot line - - Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------- -------- -------------------------------------------------------- ---------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and +hat 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 9 )-- -.---- --- �---- - -- --- ---- - - ------------ ------------------------------------ •------------------Owner and/or Contract By------------------------------------------------------------------------- -----------------------------------------------------------(Title)----------------------------------W--------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). �C FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- :�_ ' ----------------- ---------------------------------------- DATE__4 --- --------------------------------- - - REVIEWEDBY-------------------------------------------- --------------------------------------- --------------------------------------- DATE------------------ ----------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommend.ations-------- ----------------------------- ---------------------------------------------------------------------------------------------------------------------------. - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------•--- FINAL INSPECTION BY-,----- --------------------------.. Date----?--/Z-7.17------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California `/•y `.j Lodi, California Manteca, California Tracy, Ceiifor ie E5-4-21x1 , Revised 1.57 P,P,CO.`T�!O , f