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Ms"1 APPLICATION FOR SANITATION PERMIT permit No. ___,l�" "1� - ^lly (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. ` ae�ll �--------------------------------------------------------------------------- ---:--------JOB ADDRESS AND LOCATION________1_0_3Z6----- -- - Owner's Name-----it--- ---- ------------ -------------------------•- --•-------- --------- ----------- ------------------ ------ Phone------------------------------------- Address----------_10101 ---------------------------- ---•--Address----------_10101-- -------------------------- Contractor's Name_----- ------------------------------ Phone----------------------------------- Installation will serve: Residence,M Apartment House I Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ Number of living units: _ t___ Number of bedrooms Number of baths ---- Lot size ------------------------------- Water Supply: Public system [y Community system P�:_ Private ❑ Depth to Water TableyJ!_-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam F1 Clay Loam El Clay E] Adobe� Hardpan [I Previous Application Made: Yes ❑ No 9� New Construction: Yes gj No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 20a feet.) r Septic Tank: Distance from nearest well___�CQdfl Distance from foundation___!q----------Material__ �V*_. -------------- No. of compartments_,____,._._ Li uid de th_____ `--------------Capacity__ '��" -� ` ------ ---Size-----3x�- "X q p, Disposal Field: Distance from nearest well, Ma,A1_Distance from foundation___LA_-----------Distance to nearest lot line_:`___________ 1 Number of lines---------------- --- 7-,-----------Length of each line--- :-----a--------Width of french-------2f/"----------- ' Type of filter material_------1_7&_CA___-Depth of filter material:__-_�B__`______Total length_______) " .------ -� Sim v r -t: Distance to nearest well_____ Distance from foundation__----------Distance to nearest lot line______________ Number of --------Lining _ Q material- ----�GA---.Size: Di ameter___�i+ . ---------Depth------- `�---------------- pits--------:-� Cesspool: Distance from nearest well-----------------Distance from foundation---.__'.'-_---.__-,Lining material_______________________ ___________ ❑ Size: Diameter------------------ -------- --- ----Depth----------------------------- ------- -----------Liquid Capacity-- -------------------------gals.. 1 nearest building------------------------------------------ Privy: Distance from nearest well-------------------------------------- Distance from - ., ------------------------------- ❑ Distance to nearest lot line-------------- Remodeling and/or repairing (descri�ie):----------------------- ------"---------------------------------------------------------------- -------------------------------------_- •----------------- ------------------ --------------------------------•------------------------------------------------------------------------"----------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ces, State Paws, and rules regulations of the San Joaquin La i Health District. ordinances, (Owner and/or Contractor) Si ned ------ --- ( g } I CU ----- -- --- of lot location of system (Title) - -----------------------------------( ---- By:._. = } (Plat plan, showing size y tem in relation to wells, buildings, etc., can be placed on reverse si e). FOR DEPARTMENT USE ONLY �g ----------------------- APPLICATION ACCEPTED BY-----------. -- -- ---------------------------- REVIEWED BY-------------------------------- ------=--------------- --------•- ----------------------- -- --------------------- --- DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:______--------------------- ---------------------------------------------------------------------------- ----- -----------------•--- --------------------------------------- Date_'-) FINAL INSPECTION BY:---------- ------------------- "�"-�2--�5 ------------- ,SAN JOAQUIN LOCAL HEALTH DISTRICT 1 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California Y. ES-4-2M Revised 1-57 F.P.CO-