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APPLICATION -FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Exl2ires 3 Year From Date Issued Date Issued __-__ Application is hereby made to the San Joaquin Local Health District for a permit to construcWndir, all t e work herein described. This application is made in compliance.wit County 0_rdinanceSNo..,549 .+t � � JOB ADDRESS AND LOCAT ---- -------------------------------- Owner's NaW------------------------- -------------- ----------------------------------- •Phone----------I---------------- ... Address------ -----------------_---------- j`�'``` V - `" .. ° I Contractors Name----------•---------------- --•-----------------------•--------•-•--- -- _ t Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Motel Other—&-Z) Number of living units: I____ Number of bedrooms Number of baths , ___ Lot size -_- •`,'- ___xV4 .____�_-�_u------------- .. Water Supply: .Public system ❑ Community system E] Private Depth to iter Table ___.___- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy cam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ I ) New Con ruction: Y No FHA/VA: Yes ❑ No Previous Application Made: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: { (No septic tank or.cesspool permitted if public weer is availab a within 20.0 feet.) ' Septic Tank. Distance from nearest wellDi # ` �Y - ! ante fr m foyrnda ionf�� p 1 Mate I No. of compartments_------ Le----&.4F4-- - Liquid depth------- �. ---------Capacity---•-- -= --- Disposal Held, ,: Distance from nearest wel--- Distance from foundatio _; Distance to nearest loline Number of lines_-. __ Len th of each line-- " __ __ Width of trench..__ _. e gh of filter material____ . _-�/ 4 / ------ _w _ Type of filter material4 p __•_____Total, length_______ ___ ___________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation_--._______--_-.Distan to nearest lot line------------ ❑ ! Number of.pits---------------------Lining material-=-: -=------;.Sizb.w lameter------------------ - -Depth----- = Cesspool: Distance from nearest well_ _4 ----Diisstante+fro�m�foundation--------------__--.Lining material-._.------.----..__-.___.__-___.- ❑ -Li uid'Ca acit gals. Size: Diameter _ - -- ..Depth_ • 9 p y--------- - -------------- Privy: Distance from nearest well------------------------------•--- --- -___ --Distance from nearest building---------------=---------- -_----------- ❑ Distance to nearest lot line--------------------------- --- -- ------------------------------------------------------- --- --------------------------------- { Remodeling-and/or' repairing (describe)---------------------------------- ------- = _--•----------- ---------------------•------••---------------- t 3 A{ - =.f =:W= _ i ---------------------- ------------------------------- -- I hereby certify thaf4lhave,prepared this application and that the work 11 be done in accordance with San Joaquin County Y ordinances, IS ' to laws, a rule -rij,r�q'g�lationS the San Joaquin Local HealthYDistrict. - ----------------------------------------((Owner and/or Contractor) (Signed)_ :___ Oor ------ ------------------------------------ = - ------ a f --- --------------(Title)---------------------- r --- By:------------------- (Plot plan, showing size of lot, location of system inrelationto wells,-buildings, etc., can be placed on reverse side)° } f l " + F�R DEPARTMENT USE ONtY APPLICATION ACCEPTED BY------------;:-- DATE i;� 1 REVIEWED PERMIT ISSUED ---- -' -- - - ------ DATE BUILDINGPERMIT ISSUED--------------•--- - - - --- ---------------------------------------------- DATE----------------------------------- Alterations end/or recommendations:-- "�° 4 .� S +_a�-'A------- -¢� _�5 � 4 y�r. I ------------------------------------------------------------------------------------------------------------------ ------------------------------------------- -1A-------- --------------- ----------------- ------------------- ------------------------------------------------------------------- ------------------------------------•-••------------ Ij---------- ----------------------------- --------------------------------------------------------- ------------------------------- ----------------------- ----------- 1 i I -------- ---------------------- ----------------- --- ,T---- ------------_---------------------------------------- ------------ ----------------- FINAL INSPECTIONBY: 5 "4: Date...s---4--- (--��---:- - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 122 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca]ocalifornia Tracy, California E5.9-2M Revised V59 F.P-CD.