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,i -APPLICATION FOR SANITATION PERMIT Permit No. ._!_ -__/__L�.-- (Complete in Duplicate) Date issued '. � Applicati This on is hereby made to the $an Joaquin Local Health District for a permit to construct and install the work herein described, application is made, in compliance with County Ordinance No. 549. J08 ADDRESS AND LOCATION -dS ----- ------------------------------------ -------------- Owner's Name = = r ------------------------------------------------- ------•: Address Phone-- ---------------------------•------------------------------------------------------ --------------------------------------------- Contractor's Name_r_-____f - --- --------------------- ----=------ - --`__. Pone---------------•--------••---- Installation will serve: Residence? .f Apartment House ❑ Commercial ❑ Trailer Court [Motel ❑ Other ❑ } Number of living{ursits: _iNumber of bedrooms /�_ Number of baths _f1_ Lot size t ° ff Water Supply: Public f tem 4 ommunity system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes'❑ .No New Consftuction: Yes ❑ No Imo=FHA/VA; Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No septic tank or'cesspeel permit+ed'if public sewer is available within 200 feet.) Ij Septic Tank: Distance from nearest we4____'=---Distance from foundation---::7=_ No. of compart ._- Mater�L--- . r r_-_-_-- ments_-_- _------ ---------Size l(' ;3�I(- l iquid depth_� ---------------Ca aci +.- Disposal Field: Distance from neyarest well --^""----Distance from foundation__��1�'�-'Distance to nearest lot line___/ ' Nu'iber of tiines______;.e-_-y -_ -------_-Length of each line-- of trench_-.__ ��--_--_---110 ------ F or filter material_. lDepth of filter material___.l�f�------Total length___�40_--''.-_-----_ Y ------ -- Seepage Pit? Distafte'-to e rest well '----_Distance from fo dation -___-�---� Distance to nearest lot l• ,/A_ E plumber of pits . _----__----Lining material__ __.-Size: Diameter_____. __ l� Cesspool: Distance from 'nearest well-----------------Distance from foundation_____________- ' -----Lining material------------------------------------- Privy: -------- ---------- --------- �► ❑ Sizer%Diameter-------------------------------------Depth----:--------------- Liquid Ca acit - I r -------gals. Privy: , Distance from � anearest well------------------------------------------------- -------------- - - - -----D-i-s--t-a--n--c-e----f-r-o--m--- nearest b--u--i-ld---i-n-- g____----_------_---------- ❑ D'istance to Ner -- -------- . \--. . e'�� ____________ ___ ______ Remodeling and/or re airing cibe]_________ -___P d r € J ------ ----- --------------------------------------- R, ----------------------------------------------- __$ ----------------------------- _ _________--___--______---________________________________________ , _ _______________________•_ ____ __________ _ s„. __ ___________ __„_____--___-___-_-____________-_-______-____-______-_____-__ _.___-__________-_-_______--_____.-_______-_-____________________ __-__________-_-____--______--_I { hereby certify that.I have prep'Fed this application and that +he work will be done in accordance with San Joaquin County ordinances, State'laws, and r les and"regulat-/ns of the San JoaquinLoca Health District. (Signed)--------------- —u---- - - ---`'-- ---- ---- -- - caner and/or Contractor) - --------------------------------------(Title}--------------------- - - (Plot plan, showing size of lot, lo of system in relation to wells, buildings, etc., can be placed on reverse side). j sA, 1 ., FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------_(_--R d_--------------- ------------------- DATE--------_ REVIEWED BY--------------`------------------------------ ---- - --------------------------- ------------------ ---- DATE----------------------•----------- BUILDING PERMIT ISSUED--------C' ------------- ------------------------- - ------------ ------------------------------------ ----------- ------ DATE--------------------- --- Alterations and/or recornni'endations:______________________ ------------------------------------------- _ ________________________________ i I _______ --------------- 1 P�7- its Q. 2 27` ---•---------------------------------- ------- ----- ------------------------------------------------------ ------------------ f -- ----------- ------ ---- -----= FINAL INSPECTION _BY:-�, - --- 4 Date - 5� i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfre 1}-�, '` f 3 S cemora Scree# . i .y _ cF 814 North "C" Street Stockton, California - Lodi, California Manteca, California�' Tracy, California ES-9-2M Revised 1.37 F.P.CO-