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APPLICATION FOR SANITATION PERMIT Permit No. ._/ �-�-- (Complete in Duplicate) Date Issued .. „�/,___�.! This Permit Expires l Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe This application is made in compliance with County Ordinance No. 549. r y� �� JOB ADDRESS AND LOCATION-�------- - `�'"_ 'r !`/ --- Z- _I Owner's Name/_ 10Z_*!_ sk ----------- PhoneAddress '` � f .._. a Contractor's Name-----fent.-------.._--------•---. ----------------- ------------•--- Phone----------------------------------- Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ y 1 Q ` k _`�. '� --- Number of living units: __(----- Number of bedrooms --o�.._ Number of baths .�_ti'_ Lot size __________________ . ----------•-- Water Supply: Public system V[ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam k Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 50 New Construction: Yes D� No ❑ 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__)__( a____Distance from foundation__--1A-________.Material__------------------------- ------------------------ IN No. of compartments------'-----------------Size-_A, _A __4----------Liquid depth-----A4------------------Capacityvt ----_---_-- Disposal Field: Distance from nearest well--I--'r-------Distance from foundation-J-9..-________.Distance to nearest lot line__,�F____________ _ Number of lines------1•------------------------Length of each line-_41k------ ____.Width of trenchAe_4_'___,________________.____ Type of filter material+____kA-------Depth of filter material----k1_7-----------Total length----js4Q'_____-_._________________ Seepage Pit: Distance to nearest well----------------------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----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___----------------------------------------------Distance from nearest building----------__.------------------------ - ClDistance to nearest lot line--------- --------------------------------------------------------------------------•----------------------------------------------------- - Remodelingand/or repairing (describe)-------------------------------------- - ------------------------------------------------------ ---------------------------------------------------------- -------------- --------------------------------------------------------------------------------------------------------- •----------------------- -------------------------------------------------- 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 regul tions of the San Joaquin Local Health District. Si ned __�>-------_-- - -------------------Owner and/or Contractor By:----- ---- --------------•------------------------------------ ------------------------------------------------------------(Title)------------------------------------------ - - -- (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 APPLICATION ACCEPTED BY_ . ' ' � -------------------------------------------------------------- DATE----�- -��Gf ----------------------- REVIEWEDBY-------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------- --------------------------------'1�.--- Alterations ------------------------- ---='`� Alterationsand/or recommendations--------------- ---------------------------- - ----------------------------------•--------------------------.----------------•------------------------------- -------------------------------•-------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- ----------------------_---------------------------------------------------_-----------------------------______---r.______..______-_--._----__________._._..__.__ FINAL INSPECTION BY: P_-----•- -------------------------------------- Date-- rrc 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 Re,ised 8-'59 F.P.Co.