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,APPLICATION FOR SANITATION PERMIT Permit No. ------- (Complete in Duplicate) Date Issued 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 Or&n ce No. 549. JOB ADDRESS AND LOCATION. : ------------ - --------- ----------------------------------------------------' Owner's Name-------------------------IE------------------ `: Phone. Address--------------------------------------------------- 7 :. Contractors Name----------------------------------------- - ------------------------------------------- Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ .Other ❑ Number of living units J_ Number of bedrooms ;___dr dumber of baths _-_ Lot size ---__ ...C-_- .-- Water Supply: Public system ❑ -'Community system ❑ Private qe_thfo._Water Table__:"__"ft, Character of soil to a depth of 3-feet:', Sand E] Gravel E] Sandy Loam H] Clay Loam E] Clay ❑ Adobe Hardpan ❑ Previous Application Made: .Yes ❑- No ❑ New Construction: Ye FH No [I ' A/VA: Yes ❑ No ❑ �Y�. TYPE OF INSTALLATION:AND"SPEC CATIONS . 1 {No septic tank or.cesspool permitted if public sewer is available within-2004eef,) Septic Tank: Distance from nearest well. . �istan e fr foundation_ a_____-- Mate iai_ -. .___ --------------- No. of com artmenfs------ .._ __ -x Size :- �O d / UD p i 7 Liquid � -;- Capacity f D' osaI Field: Distance from nearest well -___ Distance from foundation_________________'Distance to nearest lot'iine____ Number of.�lines y L -__-------_-Llength of each line_________��0____.______I.Widfh of trench-_____;2_q ----- � �R T � 'al-----J$----------Total Jength.--=----- Seepage ---. Se p ge Pit: Distance to nearest we!!___________________.-D,is ante from founds I _ Type"of filter material De th of filter maters e a tion_______________` .Distance to nearest lot Ime________________ ,t Number of pits------#----------------Lining material----=------------------Size: Diameter__'+-------- - Depth--.-- --------------------------- x Cesspool: Distance from nearest well_'"-:7* ''Distance .from foundation________________ _Lining material---____{__ - --- F 71 ---- Depth = - Liquid Capacity gals. Priv Distance from nearest°we I-__.__ Size. Diameter-------------------------- --- - Y' - l _._______--� - ---------------------Distance from nearest building--_ -- � �"..� ❑ Distance-to'nearest rot'line------------------------ - '.� ---------------------------------- ------ Remodeling and/or repairing (describe)-------------------------- ---:-------- . ------------------------ Thereby 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'Disfri'd.- ..*. ._(Signed)------- --------------- ------- ----------- # i (Owner an ----- ------------- - - - tYsY ; [ _.. .. = -------------------------------(T- e)------------- --- Own --------r Con------t - and/or Contractor) itl [Plot plan, showing size of-lot,location of system in relationkto wells,-buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY y i APPLICATION ACCEPTED BY---- -- - -- - rDATE =' 5___________________________________________ REVIEWED BY-------------------------------- ---- - - - ---------- ---- ------------- f . 41 ----- - ------------- DATE BUILDING PERMIT ISSUED----------------- - - ---------------- --------------- ------ - DATE--------------------' .�+,- ------------------------------------ Alterations and/or recommendations:______..________ _______ i -------------- i ----------------------------------- -------------------------••--------------- ----------- --- ----- --- --_ - -------------------- ----------------------------------- ----------------------------- ------------------------------------------ FI NAL INSPECTION BY:--- --------- -------- Date.-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streof 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revises 5.57 FRCO.