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Il� I� y� APPLICATION FOR SANITATION PERMIT Permit No. ._��_.-3.-�..�... (Complete in Duplicate) 'Date Issued _l�__.S i � I 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. 5499... JOB ADDRESS ApND LOCATION r10. ..-- . ------ -----�� - Owner's Name___- ---,t! �- ----- -- - - ---------------------------------------- -------------------------------------------_-------. Phone.----------------------------------- Address----- /4 C---------- - -----S -------------------------------=---------------------------------------------- - ------------------------------ ------ - -------------Contractor's Name Phone Installation will serve: Residence,K, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 Number of living units: __(----- Number of bedrooms __3__ Number of baths ___/___ Lot size -___________________________ Water Supply: Public system ❑ Community system R, Private ❑ Depth to Wafer Table _ a ft. f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Vq New Construction: Yes 20 No ❑ 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 well_/t!o_y_tS...__Distance from i foundation_.__/�_r_____.Material._- -------------- p�city..R No. of compartments_._-.___I-__---____._Size---3_'($X_l-----.---Liquid depth----*-_-.-_--._____-___Caa �QQ Disposal Field: Distance from nearest well____Distance from foundation___I_k_`___----_.Distance to nearest lot line___. Number of lines--_-_ _2„_____ -.-- _-.-__Length of each line_-_-__T.7-_-__.-_.__-.Width of trench_.ge!_!_: `_'_......--__-___.._ Type of filter material----� _--------Depth of filter material--- $ i_t______.___Total length___.1��_.'_______________________ Distance to nearest well_____ ,__Distance from fo ndation___ __4y---______.Distance to nearest lot line-_47----_- '' ® Number of pits __-______Lining material-_-_ __ 1 Dept h---<S_'_�____________________ f,�t- ---.Size: Diameter----- --°c Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material ___________- -_______---._--______. ❑ Size: Diameter----------------- ------------------Depth------------------------------------------- --------Liquid Capacity----------------------------gals. I Privy: Distance from nearest well------------------------------------------------- from nearest building----------__________-_.-.-__._-___.___. ❑ Distance to nearest lot line------------------------------------------------------------------------ --------------------------------------------------- -------------- 4.. Remodelingand/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 ru s and regulations of the S n Joaquin Local Health District. (Signed)- C'� " v - --- - (Owner and/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). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- - � � ------ ----------------------- ---------------------------------------- DATE----- --•�-f- -=�- ----------------------------- REVIEWEDBY----------------------------------------- ------------------------------------------------------------------- ------------ DATE------ ----------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------- --------------------- ' Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------•--------•--------------------------•--------- ------------------------------------------------------------------------- -------------------------------- --------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- G -----•----•----------------•---•-------------------------------------=- ---------------------------------------------------------------------•------------- --------------------------------------------------,----_- ----------------------------•-----------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------- -11 FINAL INSPECTION BY:.... `''`------------------------------ Date ( Ti`` 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. - o