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APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Duplicate) / Date Issued 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 Ordinance No. 549. / JOB ADDRESS AND LOCATION-------- -�-/-�-`--- - - - --------------- ------------------- ---.------- ------------- ��--�4-------��--��,��--��-� /�1�--- LS.3__!a Phone------------------------------------ �.t-X.�_ Owners Name--------------- �-- _ Address---------------------------------/Z---------- ------k �-•�__tr�-rr14-�---------•-------------------------•--------------------------------------- --- ------ ------------ Contractor's Name------------------------------ Phone,------- •-•-------•--------------- -- ------------------------------------------------ ------------------------------------- -- - Installation will serve- + Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J.__ Number.of bedrooms 3---_ Number of baths ----L Lot size --------------•------ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table s' ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ . TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank ori cesspool permitted if public sewer is available within 200 feet.)-:-- i - Septic Tank: Distance from nearest well__�'n'`"_'"_"Distance from found ion__/L9_n`r`Mate�ial___ ____ -____---------------------- 7 ______ ___________ i ® No. of compartments--------.�_-__------Size----- X .---Liquid depth-----` --------- ----- 11 -�� Disposal Field: Distance from nearest well-1(0..____Distance from foundation-,� �_'?nc�Distance to nearest lot ' ® Number of lines--------.f----- --- Length of each line__�_�-----------� - ---.Width of trench---— r----- ----------------- Type of filter material----5f__��=Depth of filter material-___/_____.......Total length----- --------•-- . 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------------._____---______ ___. ❑ ---._Liquid Capacity--------------------- gals. �... Size: Diameter- --------------------------------------Depth - ---------------- ----------------- - --- I Privy: Distance from nearest well___________________ ------------------------------Distance from nearest building-----------.----_______-_--______--_______- ❑ Distance to nearest lot line-------------------------- - - ----------------------------------------------=----------------------------------------- ' Sir► R-ei�edel+n9�a-nd-/©*—rePairr�rg--{-d®�ral'e):- ------�---y-- � -----• !'_- ------------------------------------------------------ ---------------------------------------- ----- -=--------------------------------------------------------------------------•-------------------------------------------------------------------- ------------------------------------------------------- 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 J pin L -cal Health Disfrict. (Signed)-. � �O - ----- i {Owner and/or Con+tactor) - - y= , --------- -------------------------------- Tale _ _ - ----- --.. (Plat plan, showing s' a of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F R RI SENT UW ONLY / APPLICATION ACCEPTED BY------ ---- - -- -- ------------------ --- ----- ------------------------------- DATE / - REVIEWEDBY------------------------------------- ----------------------------------- DATE-------•------------•-------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------- -------------------. DATE-------- ---------------------------------------------------- Alterations and/or recommendations:-------------- ---------------------•------------------------------------------------------------ ---•----------------------------------------------..------- ---------------------------- --•----------------------------------------------------- ------------------------------------------ ----------------------•------------------ -- --------------------------------------- -Y--- ---�----------------------------------------------------ate ---- - --- --------__--------------------- Date--_.....-- •--- -------------------------•-r------ -------- --------•--------- - - -- -�- = = ---------- • FINAL INSPECTION BY---------=-- -- -�-•---='- - f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Straet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P CO.