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APPLICATION FOR SANITATION PERMIT Permit S t No. fl 31 (Complete in Duplicate) bate Issued _--2 :.. Application is hereby made to the San Joaquin Local Health District fora ermit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5r4-9,(� JOB ADDRESS AND LOCATIOX 7 _ " d ----------------------------------------------- Owner's Name.----------- Address Phone-- [.4�u- ------------ Y ---- `�--------------------------------------------------------------- ---------•------------------ ---------- Contractor's Name -----------------------------3=-------------------------------------- -------=------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ---- Number of bedrooms __/___ Number of baths-1---- Lot size ----- � X O------------------------------- Water _____ ___ _________ _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 ❑ Clay ❑ Adobe[B-Vardpan ❑ Previous Application Made: Yes [Er'N' o ❑ New Construction: Yes ��E] FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septit� Tank: Distance from nearest well-----------------Distance from foundation_------_____-._-.Material----------------__--_______-__---_-_-----___-_-. , # l'i� No. of compartments---------- ---------------Size---------------------------------Liquid dep? h--------------------------Capacity----------------------- Disposal Field: Distance from nearest 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------------------------------------------ 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: Disiance from nearest well_____________________________________ ___________Distance from nearest build ing____-__-----__------__--__._-__-_____.-. ❑ Distance fo nearest lot line--------------------------------------------------------------------------------------------------t - Remodeling, nd/or repairing (describe f:-- -----r�"� �'t `'ffjv -`/ -` � 'G !~c ��(/t%✓�C..!>L (,1 /`' :s ---------- � f �' ` R f�f ycF` �._1_ ��1=^". Vic, �'✓E N°! ""v' ' __17- ---4:i- ---- --------------------------- -------------------y-!___----_--_-__----__-__-.--_-_____--------__--_.___--------_________--_-_--___-____----__--__.____.____----____----�__-_--___---__-.-________-___-----.--._._- I hereby certify that I have prepared 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. f- (Signe �!'� i � -I -------- -----------------------------------------------------(Owner and/or Contractor) `r• y {. 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------ -�.1`•,6^�'r�-+.---------- ----------------------------------------------------- DATE------ REVIEWEDBY----------------------- - ------ ------------------------------:--------------------------- DATE-----------•-------------------------------•--------------- - ------------------------------ - BUILDINGPERMIT ISSUED------------------------------------------------------------------------- DATE------------+---------------------------------------------- Alterations and/or recommendations________________ '" -----------------•--------•--•-----•-----------•--•----•------------------------------------------------------------------------------------------•------------------------------------------------------------------------- ----------•----------------------------------------------------------- ---- -----------------------------------------------------------------------•------------------------------------------------------------------------ -----------------------------------•- ------------- - ----------------- ------------------_ ---------- ----------- -------------------------------------- ------------------•------------------------------------•--- r 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 ti ES-9-2M Revisep 1-57 F,P,CO.