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. „� APPLICATION FOR SANITATION PERMIT Permit No. .-��--. . 9 � (Complete in Duplicate) y�� Date Issued ------ -1-G 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 O dinance No. 549. JOB ADDRESS AND LOCATION---- 1 ------------------•-------------------------------------------------------------------- Owner s -----_f •i-----•------ - -- -- ---------------------------•--------------------------------------- ------------------------ Phone------------------------------------ Address. ------------------------------------------------------------- ---------------------------------------------- .. Contractor's Name--.- --- ---- - --------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �y Number of living units: - .-- umber of bedrooms . ---- Number of baths ---I---- Lot size --- -12_�__ - -D- ----------------------_- -- Water Supply: Public system Communify system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand , Gravel E] Sandy Loam ' Clay Loa m E] Clay ❑ Adobe Hardpan E]Previous Application Made: Yes E] No New Construction: Yes [ No E❑ FHA/VA: Yes ❑ No ❑ 1 TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sew r is available within 200 feet.) .�`�" � Septic nk: Distance from nearest well Q--!!"'":Distan e from found fiao Mate�i ISN --- -------------- No. of com artments---------- l p S ze 7��1- Liquid`s d�e�p�t��h�--------� --------Capacity---- --� Dispos field: Distance from nearest well_______-- istance from foundation ]?� Distance to nearest lot lin � Number of lines---------- -- --I- --------_---Length of each line--- Q-_ -I Width 10f trench.---_.- -f-.----------- Pei -- - -- Type of filter maters ' : -.----- pthtof,-filter.material=---.-r- -- - Total length------------- - - Seepage Pit: a 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------------------- material----------- -------------------------- ❑ Size: Diameter--------------------------------------De th--------------------- ----------r------------------Li uid �Capacity-- ------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-_______--.-------------------_---------. ❑ Distance to nearest lot line-------------- i Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------- ------------------------------------------------------•-------------------•---------- ------------------------------------------------------------------------------------ ---------------------------------------------- s 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. (Signed)--- -- - ----- ---------------------- ----------------------------- -------------------------------------------#---(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). 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B ------------------------------------------------------ DATE- - ! -- - ----------------------- ---- ---- REVIEWED BY------------------------------- - DATE--— --------------------- ------------------------------------- --------------------------------- BUILDING PERMIT ISSUED - ---------------------------------------------------------------------------------•---- DATE----- � Al erations and/or recommendations:-----------•----------------------------------------------------------------------------- --------------- ----------------- ----- - ---------- -- �` ` ` '- ----------------------------------------------- - --------------------------------------- ----- - ----------------------------------------------------------------------------------------- - ------ • -------------------------------------- -77, 50N------- ------------------------------------- -� --- ----- = FINAL INSPECTION BY:.- �"�� Date � r ---- 's M 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 rr5-9-21x1 , Peviseci 1.57 F.P.CO.