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r -----� APPLICATION FOR SANITATION PERMIT Permit No. ------------ (Complete in Duplicate) f This Permit Expires ] Year From Date Issued bate Issued ---3----{--------fit 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.._---------j� Owner's Name - -r--- -------- Phone Address----------------------------_•--... --- ---•-------------------------------------------------------------------- ---•-- --•-- ------------ Contractor's Name-------- '-fir Phone. --------•----- ----------------------------••--------- Installation will serve: Residence L f' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /---_ Number of bedrooms ____Z Number of baths __!__ Lot size ______ ------- Water Supply: Public system ❑ Community system [❑ Private ®. Depth to Water Table !n ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam & Clay Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes )] No ;3 New Construction: Yes 5�. 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_-_, 'Q_-_Distance from foundation__.___/_._cn------Materia'___.---- ` - .- K No. of compartments--------- _-____Size.. J_-' Liquid clepth_____ ---_._.- -------- Capacity----- -------- Disposal Field: Distance from nearest well------/-_0---Distance from foundation___-3.42--•__._Distance to nearest lot line______ -;s-- 19 Number of lines------------------,1------_-----Length of each line------------ -------Width of french------------- Type of filter material___// :-r _Depth of filter materiai___/,�---__._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---_...__________________._ 171 Size: Diameter-------------------------------- ----Depth------ ---------------------------------------------Liquid Capacity-,--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lotline_-------------------------._.--__________ 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 rules and regulations of the San Joaquin Local Health District. � r ` (Signed)___ _ _• _ rc �__ ` ---__-___...(Owner and/or Contractor) By: , c --------- -------------------------------------------- -----(Title)---------- ------ ----------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPIARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ----- ------ --�_ .r -E'er.-------------------- DATE.----- --- 7__, --��---- REVIEWEDBY ---------------------------------------------------------------------------------------------- DATE---------------- BUILDING PERMIT ISSUED------------------------------ ------------------------------- ------ DATE. ---------------- fierations and/or recommendations-----, -------------------- -------------------------------------------------------------------------------- ---------------- ---------------------•---------------------------- ------------------------------------------ ------------------------------------- ------------------------------------- --------------------------------- __ FINAL INSPECTION BY:- --'/:----- -- ---------------- Date------ - ---- - ---- -- ---"�..'�. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak S+ree+ 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised S-'59 F.P.Co, f