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APPLICATION .FOR SANITATION PERMIT Permit No. ___ _I-6--3_y 4 (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---------A _---- -__ / .------------------------ Owner's Name----------- - - ---- Ph /�' -------- --------------- ----- one-- --�'-7- -- Address-----------•--7 / �_ Contractor's Name---------- -- ---# ------------------- ------ Phone.. --„ lp - ----------------------------------------- Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---r_- Number.of bedrooms _A-- Number of baths _-/-_-- Lot size --_-_---•----------------- 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 New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well ----_ ----------Distance from foundation---------------------Material No. of compartments----- - ------------------Size----------------------- ------Liquid dei?th--------------------------Capacity--•------------ ' Disposal Field: Distance from nearest well-----------------Distance from foundation----___----`----___.Distance to nearest lot line----------------- 1 ❑ Number of lines------------------------------- --Length of each line-------------------------------Width of trench-----------------_----- Type of filter material--'---------------------Depth of filter material----------------------Total length--------------------- Seepa Pit: Distance to nearest well--_/YL_r(,_Distance'from foundation__:_J_1*1 Distan a to nearest lot line__,o� '� Number of pits.____./_-----------Lining material_ -Size: Diameter__-___. epfih__ - CA . from foundation--------------------Lining material-------------------------------------- -------------- ------------- ----. Cesspool: zea D ameter nearest well---------------DpEstlnc Dept -------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ------------- -- -- --_Distance from nearest building ❑ Distance to nearest lot line--------------------------------------"----------___--- Remodeling and/or repairing (describe)_______________- -------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------•-------------------•--------------------------------------------------------------------------------------------------------------------------- ----- 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 ru and regulations of the San Joaquin Local Health District. (Signed)-_...-'.. �- 4 ----- ------ ------- --------------------------------------------------------------- --------------(Owner and/or Contractor) By:------------------•-•----------------••------------ ------ --- Title -(Title) --- - --- - - ---------------------- (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----.�_R,_Q..--`--------------------------------------I------------------------------- DATE------ REVIEWED BY ------ DATE------ BUILDINGPERMIT ISSUED---•------------- ---- ----------------------- ------------------------- DATE. Alterations and/or recommendations:;:�_ ________---------------.--------------------- ---------------------------••---- --------------------- --------------------------------------------------------------------------- ---------------------------------- ------------------- -�,. ----------------I----------------------------- FINAL INSPECTIO Date_-. p ".. .. ------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reef 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ockton, California Lodi, California Manteca, California Tracy, California _ E ES-9--•2M Revised 1-57 F.P.CO.