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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ----- d 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___ --------------- --------------------------------- --/_'---- -------------------------------- Owner's Name _ _ '✓`f.•__ i . �- ,� - (�-; i4 a(ne / 7 5��`'r� Address----------- l ---------. Contractor's Name =� - -o tf✓(r��-------- � one----••--------------------------- Installation will serve: Residence 9/Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other Number of livingunits: __.____ . umber of bedrooms _ umber o ,baths -_______ Lot size ______ r 2_6 0 _�� •--�-Z4-T-- ------ -----------------------•- Water Supply: Public system Community system ❑ PrivafdBg epth to Water Table Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam F] Clay F] Adobe K ' Hardpan ❑ Previous Application Made: Yes E] Q No 'JNew Construction: Yes [!5 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if ptiblip sewer is available within 200 fee Septic ank: Distance from nearest well_A Distanc from#ouoation--__ ie-------.Mater' it ---- ----------- Ir - e-------- -- y No. of compartments__-___6 '__,1'____Size___ X. ________Liquid dep�__----- -___--___Capaci {Z 'Z c . Dispos Field: Distance from nearest well_.��'�tZ,.-Distance from foundation_.__ __'________Distance to nearest lot line_________ ______ Number of lines_____ ___ ____ _ _____�_ [� ,l _ �- _Length of each line��____.- __ -----Width of trench------�- ______________� Type of filter material__.-__ t,�Depth of filter material-----70V------Total length------_ate-_.:'-------5010... Seepage Pit: Distance to nearest well_-N&N_j�T___Distance from foundation_J_�.?�___:______.Distance to nearest lot line______ ,� \Number of pits________(___________Lining material---- A_CCS__-.Size: Diameter-----�_�_-__------.Depth__-__��__`___________-__ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------.__-_________ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building--________________-_____________--____. ance ❑ �t�D to fL_b� I RMI j -------------------- =OK ADVII'M� Remodeling and/or repairing (describe):__/_�}�_______`14 1_]��f'}1-�A.VAJ _____� ,'.St _____._-___�/_1f1!I , C-Q 11 mclx' '�. --------f M-------�JCQQ - --------..4__ _----- _ IS _t3l'�OF ---------------- 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 s and regulations of the San Joaquin Local Health District. (Signed)-- ----------------------------- -- ---------- ----- --- -------- ----------- - --- wn d/or Contractor) By:---- ----------------------- ----------------------------------------------------------------------------------(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---------------j6rV1-- ---------- --------- --------------------------------------- DATE------------------- ------------- 1 REVIEWED BY-------------------------------------------- -------------------------- DATE------- =�BUILDING PERMIT ISSUED---------------------- -------------------------------------------------------------- DATE----------�_------ ----------------------------- Alterations and/or recommendations:------ ----------------------------------------------------------------------------------------•---------------•------------•------------------- ------------------- :------------------�W------------------------------------------------------------------------------------------------------------------- t� -----_ -`T�--------------�1-------X ----- -------------firms ------ ' eH -_.. - - -- --- - -------------------------------- ----------------------------- f FINAL INSPECTIO BY ------------ ----- _ Date-------------- ----------- -5/ - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 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.