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APPLICATION FOR SANITATION PERMIT Permit No. (�. J_/.____-_ (Complete in Duplicate) Date Issued Application is 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;.`, � � °'cG"'y --- ------------------•-- --------- Owner's Name--14I__ •--------- ----------s--- / Phone------------------------------------ Address...----�---3---- �--- ----------1�t'------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name---- --------- -- -------------------- Phone---------------------------------- -- -------------------------------------------------------------------------------------- Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other F]Number of living units: _-I.___ Number of bedrooms -------- Number of baths -------- Lot sizeo�y, _____________________._______-----.__-_ Water Supply: Public system ❑ Community system ❑ Private f3 Depth to Water Table 10--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam PM Clay Loam ❑ ,Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No [k New Construction: Yes ❑ No)a FHA/VA: Yes ❑ 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_________________Distance from foundation------------.-------Material------------------------------._--__.._________-- ❑ No. of compartments------------- -----------Size--------------------------------Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well-_245......Distance from foundation--------------------Distance to nearest lot.line_/e1-____.-._ Number of lines--- -------- ----- --------------Length of each Gne---74---------------------Width of trench--- --------------------..-- Type of filter materia ___Jfft __Depth of filter material__/?'_-----------_-Total length_&'�-------------------------------- Seepage Pit: Distance to nearest we I________--------------Distance from foundation--------------------Distance to nearest lot line______---_______ ❑ Number of pits----------------------Lining material-----------------------Size- Diameter-----------------------Depth---------------------------- ----- Cesspool: Distance from nearest well-----------------Distance from foundation .-_.Lining material-------------------------------- ❑ Size: Diameter------------------------ - -----------Depth------------------------------------------------ ---Li Liquid Capacify gals.. Privy: Distance from nearest well____ ___-----------------------------------------Distance from nearest building_------.____________________------_____. ❑ Distance to nearest lot line----------------------------------------------------------------------- ----------------------------------------- --------------------------- f Remodeling and/or repairing (describe):__ .G- 4 ' ---------------------------- ------------- ------ I 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. ($igned) 1�.Q '�`4� - --------------------------------------------------(Owner and/or Contractor) ----- Tale (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 {�—p APPLICATIONACCEPTED BY--- - -----------------------------------------------------•---- DATE--- ----------------------------------- REVIEWEDBY------------------------ ------------------------- ----------------------------------------------------------------------- DATE--------------------------------------------------- - BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- DATE----------------------------------------------------- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ---------------- ----------------------------------------------------------------•--•---------------------------------------•---------------- F _______________.--___________._____._____----_____-_____________.---____________-_____________-------_____________________________-_. I ________________________________________________________________________________________________________________________ LL____________________________________________________________________________ FINAL INSPECTION BY:__ _______ ._ ___ bate__f_ ----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C Street i Stockton, California Lodi, California Manteca, California Tracy, California II E5-9-2M Revisea 1.57 F.P.CO-