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Wo L d APPLICATION FOR SANITATION PERMIT Permit No. +.�_ ...- (Complete in Duplicate) i� 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 LOCATIONo�/d _/ -- -�------=--5 ----------------------------------------------------- Owner's Name------- _/7-7__ x ----r.-77 t _ -/ � = Phone Address-.-----------S a_a)_-C-• !��~ a boo--—-----------------------•-------------------------- Contractor's Name----------------- �� h-•----`- --------------------------------------------------------------- Phone------------ ---------------------- Installation will serve: Residence ��partment House E] Commercial ❑ Trailer Court E] Motel El Other Eli• Number of living units: ___L Number of bedrooms GaR-_ Number of baths j--- Lot size ___ 'r— _�_X___ lJ_�________________ Water Supply: Public system 2--l'Community system ❑ Private [- Depth to Water Table � ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 9--"'New Construction: Yes ❑ No [O"IFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: + (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) - p}i nk: Distance from nearest well_________________Distance from foundation--------------------Material _____-_________._________-____________________. No. of compartments--------------------------Size-------------------------------Liquid ------- Disposaldepth--------------------------Capacity---------------Field: Distance from nearest well_ I QX��_Distance from foundation__�_l _____-___Distance to nearest lot line--5- Number of lines_______1___.___- s Length of each line-----------�_ ......... of trench-----�_ _- rr ,, Type of filter material-sf_T� 1� -Depth of filter material------ __fl_ ---Total length--------1-3-E------------------------- Seepager Pit: Distance to nearest weil _� -___Distance foundation---/O---_- _.Distance to nearest lot line_____-__ Number of pits._____------------Lining material___ A '/"___.Size: Diameter _f� ---------------------- Cesspool: Distance-from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- Size: ___________________________________Size: Diameter----------=---------------------------Depth---------------------- -----------------------------Liquid Capacity- - -------------------------gals. . Privy: Distance from nearest well_-----------------------------------------------Distance from nearest building------------_----------------------------. I ❑ Distance to nearest lot line---------------------------------------------------------------------- p f Remodeling and/or repairing (describe}------------------------------------- - -------------------------------------•---------- --------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------- -------------------------------------------------i------ ---------------------------------------------•-----------------------------------------•----------------------------------------------------------------------------- ---------------- ---------- ----- ---------------------------------•----•-- •------------------------------------------------------------------------------------------------------------------------- --------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance$, a ws, and r'uies and regulations of the San Joaquin Local Health District. (Si ned w i 2 9 L� � �< (Owner and/or Contractor) By:._.. ` --- ------------ -------- - (Title) C (Plot plan. showing size of lot; location of system in.relation to wells, buildin etc., can be placed on reverse side). h FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- --� `--------- ----------------------------------------------------------- DATE----- � REVIEWEDBY =----- ----------------- -------------- DATE--------------------------------- ------------------------ BUILDINGPERMIT ISSUED---=----------••-------------------------------------------------------------------------------------- DATE---------------------------------- -------------------------- Alterationsand/or recommendations---------------------- -------------------------------------------------------------------------------------------------------- ----------------•----------- --------------------------•-------•--------- ------•------------------------------- - --- !-- --- ----------------------- - FINAL INSPECTI --- - ------ ---------- ----- ------ Date...l-1 �j� -�� ----- 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 Revisep 1-57 FRCO.