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— _ s � APPLICATION FOR SANITATION PERMIT Permit No. tQ_, _�.�� Gig (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. JOB ADDRESS AND LOC TION '. . . '---- ` .�� Gv'_ Owner's Name 4 Gf_C_CX.- _ �'_�!--,• - - Phone - -- -- Contractor's Name 1 -----l-l/ )----------- -•---- Phone................................... Installation will'serve: Residence (Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _r_._. Number of bedrooms 3___ Number of baths --Z-. Lot size/QQ_-__!x._._10 d............................. ` Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 4._. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No M'' New Construction: Yes ga--No ❑ FHA/VA: Yes e-'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank orcesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-J.©--tc•Distance from foundationZ?.....•-------Material_r-'V 5-.-/............................ ® No. of compartments____-14-1--------------- Liquid depth__-:'r{._-------_------_---Capacity-f -a'v------- Disposal Field: Distance from nearest well---5-ppr---Distance from foundation,,•1., ..' jj,,,-,pistance to nearest lot line._��------ ® Number of lines_______.________ -----------Length of each Iine.� li. df. Q__j_L0.Width of trench.... _`l� _--___-_-........ Type of filter material..__S,- Ot A<.Depth of filter material---/r....._._....Total length..A� 0-_..•....................... 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-------------_........................ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity............................ Privy: Distance from nearest well ______________________________-.___-______Distance from nearest building-------------_--.-____.___•----._--__._,-. ❑ Distance to nearest lot line------------------ --------------------------------------------------------------------------------------------------------------------------- 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 rule and regulations of the San Joaquin Local Health District. (Signed)---- - ------ - -- --- ----------------------------------------------------------------------------------------------------------------(Owner.and/or Contractor] By: -------------------------------------------------------- ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse tide):- R ARTM NT USE NLY APPLICATION ACCEPTED BY__-_ ---- ._.t... ----- -----....... --•- DATE--- ........ BUILDING PERMIT ISSUED--------------------------------- DATE -------------------------------------------------------- ---- -------------... REVIEWED BY__________________ _________' ----- ----- . DATE...............................DATE.----------•-. Alterations and/or recommendations---------------- !.. ----•-... --------------------•--------•-------••••-•---•-•------•••----------- ---------------------------------------------------------------------------- ---------------------------•-•---------------------------------------------------•-----------------------------...•---•----•--------•---------•-- ------------------------------------------------------•----------------------------------------------------------------------------------------------------•-----.......................................•.................... ----------•------------------------•--------------------------------------------------------------------------•--------------------------------------------------•--------------..........................---••----•••--- .............................. ------------------------------------ ----------------------•------------------------------- -----------------•---------------------------•--- ------------ FINAL INSPECTION BY:. -------------- Date... . -•-----` ------------ 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.