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APPLICATION FOR SANITATION PERMIT Permit No. ----- 3__7.7--- (Complete in Duplicate) Q = Date Issued ---- Application _-Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION .._____fx -+ __.'_�__4 -- 1 __!wr---------------- ----------,--..- ----- -------------------------------------------- -------------- ------ " Owner s Name-l_ - f ^- ,- Phone --------------------- Address Contractor's Name -----------•------------------------------------------------------- ' --------- � ------ ------ Phone Installation will serve: Residence CKAparfmerif House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of livin units: '� Number of bedrooms,;-Z---- ` , g � Number of baths __�.___ Lot size ________________________•- I �—vz~-��' �✓ - ---------------------------------- 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'Rf HardpanE]Previous Application Made: Yes ❑ No)9' New Construction: Yes ❑ No�( FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) l Septic Tank: Distance from nearest wel�-_-"_----__..--Distance from foundation_- _-_ Material fl tJ i� - - ---- No. of compartments Size-,0- : Liquid depth -----q---------------Capacity -0-----• Disposal Field: Distance from nearest well'----------------Distance from foundation--_1�___---___-D stance to nearest lot , Number of lines-------------� ------;----__ Length of each line--------�___�)---r�--- Width of trench---,,�-- ----------------------- Type �f V , of filter material --- " ! -"-Depth of filter material--_--/_?-----------Total length------- ------------------------ Seepage Pit: Distance to nearest well-"--------------------Distance from foundation--------------------Dista-rice to nearest lot line--._ _--_ ❑ Number of pits----------------------Lining material Size: Diameter - Depth --•--- Cess ---------- Cesspool; I p Distance from nearost 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__--- - x" -------------------------------------------------------------------------------------------- ---------------- Remodeling and/or repairing (describe):----- ---- cj," -C_.`= hereby certify that I have - " Y Y prepare 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)_.Z_,4 � By:----------------•-------------•--------•-----`------- ---------------------------------------------•-------------- -- -----(Title) --- -- caner and/or Contractor) -------------- - _______ _ ________ 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 :; ------------- REVIEWED BY E' �._' -------------- DATE jl- - � --c- -------------- BUILDING PERMIT ISSUED.. --------- ) f T-------------------------------- ---------- DATE.---- ---- ------ --- ----------------------- -------------------------------Altera+ions and or-re omm nda ions:-_----- ----" 'r - -------------------------- - --- - ------ - ----------- �{ - _ - - --- ------ ------- 1 -c� '... - - -- ------------- ---------------------------- ------------------------------------------------- FINAL INSPECTION BY:---- -------- - --- -- ------------------- Date_-----G - ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California R Manteca, California Tracy, California ES-9-2M , Revisad 1-57 FY.CO.