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APPLICATION FOR SANITATION PERMIT Permit No.Pf__`5------------- (Complete _(Complete in Duplicate) +S` 2 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 Ordinance No. 549. e tC4 S V # e? JOB ADDRESS AND LOCATION � � -�+ ' `' =I _- Owner's Name---------- --------A----V-- -- -- ePhone'---- ---- - S✓ fiu475-1 X S Address ------------------------------------ ------------------------------------------------------- -------------------------- i;� Contractor's Name-------------- ----- -- - --------------- Phone----------------------------------- Installation will serve: Residence L�- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [) Other ❑ Number of living units: ----f--- Number of bedrooms __ _ Number of baths ___L Lot size _____:�� __________ i Water Supply: Public system ❑ Community system [] Private ®`*`5epth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe[J Hardpan ❑ Previous Application Made: Yes ❑ No 2New Construction: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is aveil'able within 200 feet.) Septic T nk: Distance from nearest well__-��_ �-{Distance from foundation_____ f-------------------------------------------- No. ___ _ No. of compartments------------- ------Size-------- -----r Liquid depth------------ --------Capacity----------------------- arest Wield: Distance from nearest well--- --_Distance from foundation--------------------Distance to nearest lot Iipe______-��`____- �/ �.l --------Number of lines______________l_ ----------------Length of each line________-_r___D__ Width of french------ _��'_____----�_____________ Type of filter material_--./ _--_ ___Depth of filter material------/_e-________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----------------- from foundation------------------- Lining material______________________________--__._-. ❑ Size: Diameter-------------------------------- ----Depth-•-----: _----------- ------------------ Liquid Capacity------ ---------------------gals. ,�..� Privy: Distance from nearest well_______----------------------------------___:____Distance from nearest buildin ------------------------------------------ Distance ____ -_________ _______-_____._ - Distanceto nearest lot line_ _--{{-- -------------------------------------------------------------------- -----------------------------------•-••-------------------- Re odeling and/or repairing (d.9scribe):---------------1Y�Vy_ -- --- ---> ---i_i__fi_� � ' --------- = `--- ..+�_ ----- }= 8` ----------- -0-�`---- --------- -�---- '`� --�---------------1--�' ' --t---------------------------------------------------------------------------- ------ --- I hereb 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. (signed)-`�r � �� ------------•----------=-.--------------- ---_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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ---- ------------------- DATE.. ------ --- REVIEWED BY--------------------------------------------- ------------------------------ ------------------------------------------- DATE--•-----------------•-----•--_ BUILDING PERMIT ISSUED------------------------------------------------------------•-------------------_------------------- DATE------ --_---------------- ------------ - - ---------- Alterations and/or recc,mrn�dati;rs:_---=_---------------- ------------------ 1� ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY-------- ------ --------G 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-9-2M 8-51 Revised W-2100