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� rvKVFFI� U5 ------------- APPLICATION FOR SANITATION PERMIT Permit No. __.. _ .!•�. '� ------- -------- -------- (Complete in Duplicate) - ._:' ._ ._ L,- --- -------- --------- -- This Permit Expires 1 Year From pate Issued 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. 5�1"� JOB ADDRESS AND CATl.O 4--' / / f Owner's Name------------ ------- ? _ `� - -----------b�----1-�--•A-G--� ----- ------------- hon "75 7 Address ------------------•-------- ---- c Phone- -4." Contractor's Name---e - -- ----- - !.. cl- � -r- ---------- -•--- .��------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ /!Motel ❑ Other ❑ Number of living units: ---- Number of bedrooms I... Number of baths J_._ Lot size --- Water Supply:Supply: Public system ❑ Community system ❑ Private K Depth to Water Table-SZ'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam g Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: [If yes,date................ .) No ❑ New Construction: Yes ❑ No K 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 wellL... Distance from foundation-------------------Material----- ------__- r �5irN; No. of compartments----------------- -----Size-----••--- --------------------Liquid depth------------ -- - --------Capacity---------- --------- Disposal Field: Distance from nearest well-_� _ -,-Distance from foundation__SRV P_ _---_Distance to nearest lot Number of lines..__C`Yt —----------------Length of each line-- 5 .___. . -----Width of trench..-2_4•�----`(------------------ Type of filter material__ F-t•_I<1_____Depth of filter material-___. .--_-Total length-------__5 _- -------------------- Seepage Pit: Distance to nearest we!!_------------ _......Distance from foundation--------------------Distance to nearest lot line_--.--_.-_---_ ❑ Number of pits------ -r------------Lining material---------- - ----------Size: Diameter------------- -- Depth----- ------------------- Cesspool: Distance from nearest well-------------_---Distance from foundation-.-.----------------Lining material.....---------------___-.__.._--___-_ ❑ Size: Diameter---- ------- ---------------- -- ----Depfh_- --------- ---------------------- -------------Li uid Capacity-.------------- q ------------gals. \ Privy: Distance from nearest well ____.....__------------------------ -_Distance from nearest building ❑ Distance to nearest lot line-.--------�-------------- Remodeling and/or repairing (describe):-------- _-.-�------- �� ------- ------------------------- --------------------------- _ ---------------------------------- --------------------------- ----------- - -------------- ------------------------------ -------------- ------------------- --------------------------------------------- --------------------------------------------------------------------------•------------------------------------------------- I hereby certify th have prepared this application and A t the work will be, done in accordance with San Joaquin County ordinances, State laws, a d les and regulations o e San Joaluin Local Healt -Dlstrjct. (Signed)---- - __ (Owner and/or Contractor) - ,-' BY ---------- ------ --------------------------------(Tltle)-----------------------._... _-.------- - -- (Plot plan, showing size of lot, loc6tt of system " relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -.(e ------------- REVIEWED BY -------------------------------------------- ----- ----------- ------- DATE------------ BUILDING PERMIT ISSUED-------------- ----------------- -----------------._ DATE Alterations and/or recommendations:____-_..._____..__ ------------- _ -�4 -. r FINAL INSPECTION BY:.. --------- --- Date------- ... - ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT n 130 South American Street 300 West Oak Street 124 Sycamore Street Stockton,Californiaest 9th Street E9.9 REVISED 8-59 F.F.00.2M 6-60 Lodi,California Manteca,California ~"` lracy,California