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1 'APPLICATION FOR SANITATION PERMIT Pe'rmif No. ' {Complete in Duplicate} / Date Issued _____/_�_lEi1. � k 11 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. "} �Y This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCATION I/d 1-116 y Owner's Name----------------------------- �---j---------------- sU A, y ---------j----•--• ---- - • ------------------------------ ------------------ ---- -- ------ Phone--------------�•--------.-._-...- - Address �� = ••- s-"`�raR-� =----- -----------------------------------••------- Contractors Name-------- '-�-------•---------------------------------I----•---------------------------------------------------------- --•---- -- Phone------._----------•---------------- Installation will serve: Residence 0-Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot I ❑ Other ❑ Number of living units: ,,/---- Number of bedrooms_._ Number of baths Lot sizejO ' ------------------------ Water Supply: Public system E �ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [q/Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes 2- f�o ❑ FHA/VA: Yes ❑ No 1� TYPE OF INSTALLATION AND SPECIFICATIONS: " (No_septic tank or'cesspool permitted if public sewer is available within 200 feet.) a r Septic Tank: Distance from nearest well__________e-----Distance from foundation___________________Material----------------------------------------------- El aterial---___________._______.__________----________❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearesf well-________________Distance from foundation--------------------Distance to nearest lot line________-____-_- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length-------.-_________________-_-___-_________ r Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____._.__.______ ❑ f Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Deptl-L_-1------ ---------_--- ---- I � Cesspoo Distance from neaFst wellb�P____Distance fr m foundation__!-a____.___.__.Lining material_ _ � _____________ fey t Size: +er.--1 O.� Depth 1 ------ Liquid Capacity C1 gas. 4 Priv Distance trom nearest well________________________________'_______-._-_-Distance from nearest building _r ❑ Distance to nearest lot line------------------------- ------------------------------ --------- Remodeling and/or repairi1 g {describe}:__.:_ _________ ---- -------------------•------------- --- d __ __ Y '". ------- - -- ---- - -- - ------------------------------- ---------------------------------------------------------------------- --------------------------------------------------------------------------------------------------•------------•------------------ ---------------- I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County r nX(Sedces, State laws, and rules and regulations of the San Joaquin Local Health District. ordinances, 9 )-^' 'r J ^r n_4_17 -., ./`- `-------------------------------------------------------------------------- (Owner and/or Contractor) 1 By:--------••----•----•--------• -- ---- ------------------------------------------------------------------------------------------(Title}--=------------------------•--------•--------------------------- " (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------------------,.. REVIEWEDBY------------------------------------- -A - - --- ----------------------------- - - - ------------------------- DATE--- i ; j Alterations and/or recommen ----------------- -----------------------------------------------•------------------------------------ -BUILDING PERMIT ISSUEDDATE._ N ----------- ---------------------------------------- Alterations ----------------------• --------------------------------- -------•-----------------------•------------------------------•---- - ------------------------------------------•-------------------------------------------- t --•----•------------------•----------------•------------------- ------------------------------------------------------ ------.--------------- --------------------------------------- --------------------------------------.------------------------------------------•------------- 3 _____________________________________________________________________________________________________________________________________________________________________..______...._________-_.______-____________-___.-. _____________________________________________-------------------_-------______ _ _-___-_.__-______________...__._________--. _________________.________.__..__________.______-__-„_._____.__ _____ _________ .� �- -- s1 FINAL INSPECTION BY: i►E- 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 ES--9-2M , Paviseo 1-57 F.P,CO.