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APPLICATION FOR SANITATION PERMIT Permit No. --.._!__/-_/..__ (Complete in Duplicated / 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. 5 9. . JOB ADDRESS AND LO TION}. ------- �-� � --4L- ------- -- ------------------------------------------------------• ----- Owner's Name ---------------------------------------------------------- ------------------------------- Phone?_-,-^_3/1r� --- Address ---------------------------- -- -- Contractor's Name------------------ - - - ------ - ----------- Phone. j '_ __ Installation will serve: Residence Apertme6f'House ❑ Commercial ❑ Trailer Court ❑ Motel�/❑ Other ❑ Number of living units: �- N ber of bedrooms ---V_ Number of baths _�__ Lot size ___2S�✓�-_ -----_._______________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 4/ f. Character of soil to a depth of 3 feet: Sand ❑ Grave ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction. Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) otDistance from nearest well-----------------Distance from foundation______.________..__.Material_-_._______________-_____-__--_---_----..._----_. No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- i 's ieid: Distance from nearest well from foundation------------------- to nearest lot line----------------- Number,ofalines-� •_'_„^_-� - -----. -`'Length of each line------------------------------Width of frenc2h---f.----- _._04 _ - Type of filter material-------------------------Depth of filter material-----------------------Total length---_____-__.___•--._--_-___._._.___._.__._ Seepage Pit: Distance to nearest wells Dista ro fo dation-40_f..----Distance to nearest lot line-_/-d------ Number - -Number of pits f----------Lining material�._Size: Diameter-- = - - .Depth- �:�---------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ElSize: Diameter--- -------------..------------------Depth--------------------------------- ------------------Liquid Capacity----------------------------gals. \ Privy: Distance from nearest wel!-------------------------------------------------Distance from nearest building---_----------------------------------- 1 ❑ Distance to nearest lot line-- ------ ------------------- ----------------------------------------- ------------------------------------------------------------------ - r Remodeling and/or repairing (describe):--------- -----------------------------------------------------------------------------------------------------------------------------------------------• JJ. ---------------------------------------------- --•-------------------------•----------------------------------------------------------------------•--------------------------------------------------------------------------- 1 -----------------------------•-----------------------•--=--------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby tify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a e laws nd a and reg tions of he San Joaquin Local Health District. (Signed) �-_----_ ___- _ ---------------------------------------------------- ner and/or Contractor -------------------IP61 [I/✓ (Title W—OW--------------------------------------------- Br• )--- f (Plot plan, showing size of lot, location of system in r ion to wells, buildings, etc.,'can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- -- -------- -- ------- ------- --------- ----------------------- DATE-------------- ------- REVIEWED BY-------------------------------- ---------- - -- -- ---- ------------------------------------------------- DATE--------------- - .�-- - ---- -------------------- BUILDING PERMIT ISSUED------------- ------------ --- - - -- ----------------------------------------------- DATE-- -- - t--------------------- Alterations - - - Alterationsand/or recommendations: --- ---------- -----------------------•-----•-------------------------------------------- ------- ------------------------------------------- ------------------ A-4- 4ef " --------- --------- --------------•------------------- -----------•--------------- -------------------- ------------------------------- -- •------------------------------ - -- ---'--__---------- - -f------------------------_ //1 FINAL INSPECTION BY:.__ ___ __.__ �� 7-- ".) 7 Date ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy. California ES / t Revised 1.57 F-P.Co.