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1 APPLICATION FOR SANITATION PERMIT Permitqye (Complete in Duplicate) < +,w �• �dd4 � 3 jr Date Issued l-L�— 10/.7 a Application is hereby made to the San Joaquin Local Health District�or a permit C onstruct and install the work herein described. , This application is made in compliance with County Ordinance No, 549, JOB ADDRESS AND LO ATION.. (--- -= , ------- ---------------------------------------------- ------------------------------------------------ --------------------- JOB ADDRESS AND LO�ATION-- I . Owner's Name----------- - -------- ------- -------------------- ---------------------------------------- Phone_ �y,� Address ,1 -r� -------------------------------------------------------------------------------------------------------- Contractor's Name----------------6--------.dj-.1 P ----------;------------------------------- Phone---------------------------------- Installation will serve: Residence 0--A' partment_H_.ouse ❑._-Commercial_-❑-__ Trailer Court .E] Motel._, Other ❑ Number of living units' _/----- Number of bedrooms .3--- Number of Baths ---I_ Lot size -___ -y`___"L- ------------------_________.___ 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 �ardpan ❑ Previous Application Made: Yes ❑ No g-"New Construction: Yes No ❑ FHA/VA: Yes ❑ No [�— TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ?W46V�_C� _ p from nearest wells _-Qistance from found'ation---I _________.Material_____ r -- -------------- 'Size - = y-------Liquid depth-------`y------ p y--- Se tic Ta =Uk Not of compartments.-_-_-�---_._ Ca acit ______ Number from nearest`Weil--1�Dis}ance from foundation___ll*I__ Distance to nearest lot line. Disposal Fie stance of lines--------7- -- -------- ---------Length of each linelt_3)--- -r(J''�---Width of trench---- -{�-��----------_-------- Type of filter material ------------Depth of filter material----IF.._............Total length------ZL'I.-0--------------------------- �i Seepage Pit: Distance,to nearest well._____________________Distance from ,foundation---____---------_-..Distance to nearest lot line----------------- Number of,i g p i _ Cesspool- D stance fromsnearest well--Lining r'-'Distanlce from foundation Diamet-- -----------------------Linin mateDepth al t�____ _________________________'r � 4 ❑ Size: Diameter---------------•----------- ----------Depth----------------------------------- ------Liquid Capacity----------------------------gals '. Privy: Distance,l rom nearest well------________________________________s----------Distance from nearest building__________--_-------_---__--------_------ [� Distance to nearest lot line-------------------------------=-`---------------------------------- ---------------------------------- -------- Remodelin and or re airin ' [describe)___________________ ` ' � ' "� t ' ------------•-------------- ----------------- ----------------------------------------------------------------------------------------------------- . -o -------------------------------------------------------------------------------------------------- ------------------------------------•-------------------------------------------------------------------------------- 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 reeg,uullatio of the San Joaquin Local Health District. ' (Signed)--- ------ - /----- -------------------------------------------------------- ------------------------(Owner and/or Contractor) By:--------------•------------ ----------.-----•------------- --------+-----------------------------------------------------------(Title)_------------------------------------------- ------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). n k FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ii3Y '4 ------•-°-------t---- ------------ DATE---- --------------------------- 4 BUILDING PERMIT ISSUED_'` DATE-------------}------------------------------------------------------------------------------ ------------------------- --- REVIEWED BY---------- Y--------- ---------- ---------------- - -------------------------- --.:-_---------�------------- -- ------------ ---------------------------------------------------------------------------------------------- DATE----------- -------------- - Alterations and/or recommendations______________________________ --------------•---------------------------------- ;i -•--------------------------------------------------------------------------------------- ------------------------------------------------------------------------•---------------------------------------------------------- ------------------------------------------ -----------------------------------I------------1----------------------------------------------------------------------------------- ---------------------------------------------- , ik ----- ----------- ------------------------- --------------------------------------------- FINAL INSPECTION BY------ = ate .t- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street!" 30D West Oak Street 132 Sycamore Street � 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised 1.57 F-P.CO-