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IN rqq� P11 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �� Date Issued _--__ ____�Ars' �1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This�S2application is made in compliance rwitA Cou ty Ordnance No 549"7 E _ f4 f 6-A4&j A4 z6 CD JOB ADDRESS A OCAT ON___ __` _ 01 f—ZDO 7 -- ---- - - -- - - - - 3 Owner's Name---- Address ame u f,---- -- �' � -------------- Phone----- ----•----------------------- Address--------------- - Q ----------------------------------------- Contractor's Name--------- - ----"� -----�/-- --- -------------------- -------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units:" Number of bedrooms _=T!!! Number of baths -- Lot size _X41',e��1'._____-_______________________- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam JP-1flay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes UNo ❑ PHA/VA: Yes ❑ No N TYPE OF INSTALLATION AND SPECIFICATIONS: �n11 (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) (V .. ptic nk: Distance from nearest well_________________Distance from foundation___________________.Material--_-------------_--_---__---____--------____--__. 'J No, of compartments-------------------------- •-----------------Liquid depth---------- ------------- -Capacity--- --------------------- 1711 ' pos field: Distance from nearest well-----------------Distance from foundation-------------------- to nearest qlo�t�line________________ Number of lines-------/___._.__ Length of each line-_,04M .Width of trench___Al?_r--_________________ Type of filter material-_-f Depth of filter material_:_.� �`_._____Total length------fZ __ ___________________ e a Pit: Distance to nearest well----------------------Distance from foundation____._...___....___.Distance to nearest lot line--------.-------- � ' Number of pits----------------------Lining material----------------------.Size: Diameter------------------------Depth--------------------------------- t esspool. Distance from nearest 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-----------DD-----�--------------------------- ---------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)------------- �"�f----__----- I ----------------- .------.--------------------------------- ------------------------------------------------------•------------------------------------------------------ ---------------------------------------------------------•----------------------------------------------------- --------- --------------------------------------- -----------------------------------------------------------------------------------------•-------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, anrules and re ulations of the San Joa uin Local Health District. T1L _-__-_- - _ Contractor (Signed)--------------- - - ------� ( � y _ 1' By:-------------------- �� ---------------------------------------------------------------(Title) ' ' ------------------- (Plot plan, showing siz of lot, location of system in relation to wefts, buildings, etc., can be placed on rev se side. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -- - ---- --------------------------------------------------------------------------- DATE------------------•------- ��- ----- REVIEWED BY --------- -- --------- ------- ---- -- -- - ------------ DATE-------------- ..--------------------------- BUILDING PERMIT ISSUED------_----------------__ __ DATE------ � Alterations and/or recommendations: ----------------------•--•----------------------------------- ------------------------- ----------------------------•-•---- --------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------•-- ------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ----- ----------------------------------------------------------------------------- ------------------------------------------------------------------- ------------------------------- ----------------------------------- FINAL INSPECTION BY:------ ----------- ----------------------------- 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-9-210 . Revisea 1.57 F.P.CO. s•