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APPLICATION FOR SANITATION PERMIT Permit NO .,'�_.. (Complete in Duplicate),VA /- I ' 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 Ordina No. 54 JOB ADDRESS D L CATI4m (0.a i;;tEi4 .......................................... Owner's Name--- ---- ----------- ------ -- ••-- •-•---•------•---------•-- ---------------------------- ----- --- _. Phone --- ...................... Address-------------1- ••---- Contractor's Name Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ ' Mot 1 ❑ +Other�❑ Number of living units: __�-.__ umber of bedrooms a--- Number of baths •__�... Lot size __�.��r/�t.lJ..•..:................... Water Supply: Public system �ommunity system ❑, Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam ❑ Clay [IAdobe Hardpan Previous Application Made: Yes E] No F( New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted ' ublic s er is available within 200 feet) Septicnk: Distance from nearest well-- Irv- 4aDist a froou �on� ajjeyial =- - -.. ._..w� ' No. of compartments-_____- -------- iz X. .Liquid depth_-. !f__'__--.__ -..__-_Capacity_ .. • ' _._ Disposal Field: Distance from nearest I_ Distance from founds ion :Dstance to nearest lot li a-• - ❑ Number of lines ------ �ength of each line �� y_ ' idth of trench _,_._.:_._ ' '7 t- - Type of filter mate h of filter material_..---� ��------Total length------------- J .. , Seepage Pit: Distance to nearest well _-_---Distance om fo ndation__...A.)....... to nearest lot line.---5..._....... �^ 1-71 Number of pits. _-___-/__ __Lining material...___ __ _ .. izg: Diameter------J--- °*..___Depth_____________a`L_.4-t t� Cesspool: Distance from nearest well...... .........Distance from oundation--------------------Lining material- �° ❑ Size: Diameter--------------------------------------Depth-------- -------- ------Liquid Capacity...-------• -•.._......._gats. Privy: Distance from nearest well-______ ___________ ___ __: ._ __-____-____Distance from nearest building------------------------------------------ Distance _________--__-____. _--•. __.-_---.Distance to nearest lot line--------- -------------- Re ode dor re airm descr a ... 9 / p 9 I ) . ------- ---- .� ------------- ••-----------•--=--•-- ---- .--- -- ----- ----- .............................................. -----` I 1 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 regulati s of the San Joaquin Local Health District. U (Signed)\G[_ - ----------------•---------------------------------- ----._Owner and/or Contractor) ( / actor) 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- ------ ------ ------------------ ---------------------------------------- DATE ...-----•--........•------- ...................... REVIEWED BY.............................. --------------------------------------------------------- DATE- BUILDING PERMIT ISSUED--------------- -__ ------ ------ ----- DATE..._ _. Alterations a retro " . •.._...__.. t ---- - --- - ---- ---------- -------- ---------------------------------------•-------------=-----------•----•----------•-•---------- FINAL INSPECTION BY:.' ---- _- ---- --� --------------------------- Hate------- r/ ..--------�---.: ? SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C"Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P.CO.