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APPLICATION FOR SANITATION PERMIT Permit No. _ _.`J--- ._.___ (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 Ordinance No. 549. JOB ADDRESS AND LOCATION--------- _f-- Td3 I �?__ r-------------- -------------------------------------------------------------------------- Owner's Name------------ --------------------------------------------------------------------------------------------- Phone- !110---------------------------- Address-----•.......--1--4 _ � _.a ++_• -------------------------- --•---------------------------------------------------------------------------- Contractor's Name--------i7._e_ .'s,-a•----------------------------------------------------------------- -------------------------=--------------------------- Phone---------5rT39-55--------- Installation will serve: Residence B Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----1- Number of bedrooms ____1_ Number of bathsl------ Lot size ----87:7--W__________________________________________ Water Supply: Public system ZI Community system ❑ Private ❑ Depth to Water Table la__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ Previous Application Made: Yes ❑ No E3 New Construction: Yes 0 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer'is available within 200 feet.) Septic Tank: Distance from nearest well__D.OnP___Distance from foundation------8--------- ________- F] No. of compartments---------2------------- Size-_61. -_4'XA----------Liquid depth----l t____--____Capacity-----WO---------- Disposal Field: Distance frorr7 earest well-----------------.Distance from foundation--------------------Distance to nearest lot line_________________ 1 ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length-------------------------------- ---------- Seepage Pit: Distance to nearest well ___;Cania-------Distance from foundation------ZO-------.Distance to nearest lot line.......... ._____ .• Number of pits--------I------------Lining ------Size: Diameter---------42`t-------Depth------ Cesspool: Distance from nearest well-----------------Distance from foundaiion-------------------.Lining-material------------------------------------- •- ❑ _Size: Diameter Depth= -" :===_=-= === ;----- Liquid Capacity-----------------------------gals.. . - Privy: Distance from nearest well--- ---------------------------------------------Distance from nearest building__-_-_____________-__-.---_______-_-_____. ` ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe): I ------- f5Ie_w---S -st-em------•------------------•-----------...---------------------------------._...------------------------------------- -•--------------------------------------•-----•---- --------------------------------------------------------- -------•- •-------------------------------------------------------------••---------------- --------------------------------•-•------------•----------------------------------••---------------•--------------------------------.---------------------------------------------------------._...----------------_-------- ----------------------------------•--1•---••------------------------------------------ --------------•------------------------------------------------------------------------------------------------------- + 1 hereby 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) De_lLa----------------------=-------------------------- (Owner and/or Contractor) By:.........................P( r.'�.' _.i1=ts ...ua------ .�__-C (Title) ii 4 -�_ s '------------------------------ (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 F APPLICATION ACCEPTED BY_ __. ------------------------------------------------------------------------------ DATE- -------------------------------------------------- DATE---- � -------------------------------------- - REVIEWED BY--------------------------- - BUILDING PERMIT ISSUED-------------------------------------------------------------- -------- ------------------------- - DATE-------------- -- ----------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------•------------------------------------------------------------------------------------------------ ----------------- E --------------------------------------------------------------------------------------_----------------------------------------------------- ----------------------------------------------------------------------- -• - ------------------------------------------------------------------------------- -------------------------------------------------------I------------ FINAL INSPECTION BY:------- :---------------------------------- Date, r`3 '' 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 r