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1 J$ - APPLICATION FOR SANITATION PERMIT Permit No- ____l _3�--_ (Complete in Duplicate) a f� 4 Date Issued ----- f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATI �c - - 1 --------------------- ------------ ---- Owner's ltd -- - ------- Owner's Name "' ------------------ Address j 1 }�,,� � --•----•----------•-------- -- --=---- - �[f `oma i Address---------- r C)_ s_a _ -----�----�J_- --- Ph ----------------------------- ------------------------- .F ------- Contractor's-Name-------��--�-�-=-�--- ---------- ----•-----------•--•------------•------------------------••--------- ---- - Phone-------------- . --•------------------------------ -------------------- --------------------------------------Installation will serve: Residence., penmen# House Commercial ❑ Trailer Court ❑ Motel ❑ iher Number of living Units: -------- Number of bedrooms-.I —..Number of baths L----__-- Lot size __ ---- - --Q: F --•-------•-------------- Water Supply: Public system VCommunity system ❑ Private ❑ Depth to Water Table -------- ft. "'f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--H-',rdpan ❑ Previous Application Made: Yes ❑ No P--�New Construction: Yes E'T'No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIO_ NS: No septic tank or'cesspool permitted if public sewer is available within 200 fee .) Se tic Tank: Distance from nearest well---&�_Distanc from foundation_--_- + .M trial--- No. of compartments-.. --_----------Size��L1_. 7�- Liquid depth- --------- ------------------------- DI's - Capacity �G G cJ poral Field: . Distance from neares wel /`�{ - Distance from foundati Distance to nearest lot line_-- Number of fines------ --------------- ---- ' Len th of each line__-- t0 ---- - 9 -------��__._.Width of trench_, _ Type e of filter material-_ --- Yp - -- ---------Depth of f Iter material----- - -------- ----Total len #h-_- g '� . Seepage Pit: Distance to nearest_Vwell`:`_- �__---Distance from foundation_-___"____-----------Distance to nearest lot line__.____-.________, Number of pits----------------------Lining material------------- -------- Size: Dia meter-----------------------Depth---------- ------- Cesspool; Distance from nearest well_______-._______Distance from foundation___________________linin material-_.__-________-_.------------------ - ❑ Size: Diameter_ _~ --- _ p ' "rgepth"' ----------- --- --- -- ---------Liquid Capacity---- -----------------------gals, I`r Priv T - , ., ._,f_ Y� Distance from nearestwell _.__----.-_______.________..__Distance from nearest building__--:____--- ----_---------- -line Distance to°nearest lot-line_______ ^ K -----;-=------------------------------------ ---------------------- •-- -------------- Remodeling and/or repairing {describe)________________ I ------------------------------------------- .° ---_- - ------------------.----------- •---•----- ------ ------------------------------------ -• ---- ,. ____._f__________________________ _ - I ---------------------------------------------------- ------------------- - -----------=------------------------------------•--------- � ' I.hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin,Counfy ordinances, State laws, and rules-and rreegulations of the Sart Joaquin Local Health District. Signed).�J1C.)------------- " "._� ----------------- ---------•----------------• ( wrier and/or Contractor) or C O don rat 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 REVIEWED BY - ----- ,f--- i - ti -- ------ -=------------ ------- ------------ -- -- -- - - DATE------- BUILDING PERMIT ISSUED_____________ ______ - - - ------------------------------------------------------ ATE--- Alterations and/or recommendations:__- _ --- -- - _ -------- ------------ --- --- --- ---- - -_ __ - o--fs " omu rC - - --- --- -- - - � ----- , �� . --------•------- ------------ ----------------------------•----------- – – ----------------------------------------- " --------------- - ----------------- FINAL INSPECTION BY:_-_- Date------ SAN JOAQUIN LOCAL H TH DISTRICT 130 South American Street 300 West Oak•Street 132 Sycamore Sfreet 814 North 'C" � Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revises 1,57 f,P.00.