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APPLICATION FOR SANITATION PERMIT Permit No. ..11-__ CJ__rJ J / (Complete in Duplicate) I Date issued .___�,1-��--� � This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit ff onstru i an rns 11 he work herein described. This application is made in compliance with County Ordinance No. 544. s�.'� °fir -------- ----- JOB ADDRESS AND LOCATION---------------------------- -------- < Phon Owner's Name__.. ________ rU__ �l" " ------- - - •----- Address. s ----------------- Contractor's Name----------•-- ------ Phone..........-•---------------------- i ------------------------------ - Installation will serve: Residence ®" Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.--___ Number of bedrooms / "f "---------------- C -_._ Number of baths _ ____-- Lot size _-- ---------------------- Water Supply: Publiclsystem [ Community system ❑� Private ❑ Depth to Water Table _______ ft. Character of soil to atclepth of 3 feet: Sand ❑ Gravel F1Sandy Loam ElClay Loam E] Clay ElAdobe 2 - Hardpan ❑ a, Previous Application Made: Yes ❑ No [?FNew Construction: Yes ?[ No ElFHA/VA: Yes ❑ No E] i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted-if public sewer is availa6le within 200 feet.). weli'7 �'-r--Distance from foundation_/�1_-_�------Materia4__,��..____G.ra eel--------- Septic Tank: Distance from nearest ElNo. of compartments_-------5Z--"----------_Size__ .__ '--5___ `, ---Liquid depth---------Z ------------Capacity-----19, ---------- Disposal Field: Distance from nearest welL- �-Distance f om f ndatioa_�B_e__----Distance to nearest lot line__5 .____ ❑ Number of lines_____-_�----"""- ---`-------- Length of 'e-a '-` -----------Width 'of trench__. '- ...... --------- Type of filter material__ __ e'_e Depth of filter mate ------Total length-_ -i4l----------------------- I Seepage Pit: .Distance to nearest well----------- Daa from foundation- 1 -Distance to nearest lot line-------- 171 - ❑ Number o p ning material pameter._- p -------------------- I ------- Cesspool: Distance from nearest well________________Distance from foundation.___.______-.__.__ Lining material_-___.____-______-_____.________._._. ❑ ---------------------------------`Size: Diameter ----Depth--------------------------- l.----- ----------------Liquid Capacity----------------------------gals. ., Privy: ,Distance from nearest well------------------------------------------------Distance from nearest building-------.------------------------------- -- Distance to nearest lot line- ------------ ----------- _..------------------------------------- - -------------------------------------------------- ---------------- Remodeling and/or#repairing {describe}: 4 = -------------------- 4� = = ------- - -----------------7 t 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. . i f ....(Owner and/or Contractor -- -- ------ I - ---------------------------------------------------------{Tit --- ------ --- ------- ---- - ---- } (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--------------------------- i--- ------ -- ` DATE i`' DATE--- ------- -r'�------- --- ------------------------ - REVIEWED BY ; -------- BUILDING PERMIT:ISSUED-------------- ---------------- DATE -- -- ------------------------------------------------ f Alterations and/or recommendations:--------------------------------- ------------- ------------------------------------------------- --------- -------------------- --- -- J -------- ------------ Date6 FINAL INSPE U . SAN JOAQUIN LOCAL HEALTH DISTRICT t30 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street t Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 6-'59 F.P.00.