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`/7 , 6;1 Permit No. APPLICATION FOR SANITATION PERMIT � w (Complete in Duplicate) Date Issued ____ Z-3qf.-r,-7v 4C4,f Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal{ a work h rein described. ipliance with County Ordinance No. 549. ------------ JOB ADDRESS A LQCATION-------- ""` .�. A ---- ---- /� Phone Owner's Name--- Aa. Via_ �.t 1 Address----- -- - ;7------- --t------�-- � ,` � � //!!�� / Contractor's Name_----------- -- _ --- -- --- ----------------- Phone-STs_.r--_ o Installation will serve: Residence � artment House El Co E] Trailer Court ❑ Motel El Other [j'� Number of living units: -------- Number of bedrooms -------- Number of baths .oZ__ Lot size __�- ---- - -'.__�.�-'-�-�-l-f--- ----- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ---- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [Flew Construction: Yes ❑ No Z�—FHA/VA: Yes ❑ No 54�-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ti ank: Distance from nearest well_________________Distance from foundation--------------------Material____--_________---____-_________-_____________- ® No. of compartments-------------------- -----Size--------------------------------Liquid depth--------------------------Capacity---------------------• _ pos I F Id: Distance from neares well- "___Distance from founclation__/d-/-------Distance to nearest lot line_,/4-_ _-- # r� i/ r� �� Number of lines---------------------- Length of each line__ -- -- --------l-----.Width of trench__--r` ------------------ Type of filter material-__S_�_ Depth of filter matersaL__. T_ ___-___Total length ____-_______._ Seepage Pit: Distance• to nearest well----------------------Distance from foundation------------.-------Distance to nearest lot line__________.•____. W ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------------------- ------ Cesspool: Distance from nearest well________________Distance from foundation___-_________._--.Lining material..--.:_________---__.__-________-__._. gals. Size: Diameter--------------------------- ---------Depth-------------- - ---------------- ------------------ Liquid Capacity---------------------------- tr '. ❑ , Privy: Distance from nearest well___________________ ______ __Distance from nearest building______-------------------------------- `r ❑ - --------------------------------------------------- , Distance to nearest lot line------------------------ ------- ---- ------------ ------------- ------------- ' Remodeling and/or repairing (describe)--- ----------------------------------- ------------------ --------------------------------------------------------------------•------------------------------------ ----------------------------------------------------------- ------------ ----------------------------------------------•-------•------------•-----..... ' -- --------•------------------------------------------------•---------------------------------------- ------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, SV ws, and rules and regulations of the San Joaquin Local Health District. I Owner and/or Contractor) (Signed)--------- --------- ( / By--------------------------- (rG/ -- _ -- `"` (Title) V ' --------------- (Plot plan, showing size of lot, location of system in relaro/n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _. DATE- -------------•------------------ ------------- ---------------------------------------------------------------------------- REVIEWED BY --------------------- DATE BUILDING PERMIT ISSUED--------•------------ ---------- ----------- -------------------------- - ------------------------- DA ------ ------------------------------------ Alterations and/or recommendations________________________ -------------------------------- - --- - ----- FINAL INSPECTION BY:--------------_-------- --- ---- - / Date--- r �` --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street TracCalifornia Stockton, California Lodi, California Manteca, California y. E5-9-2M , Revised 1.57 F.P.CO.