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\ APPLICATION. FOR SANITATION PERMIT Permit No. _/9_ 1 li D i C ( omplete n 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. 4 ----------------------------------------------------------------------------------------------------------- JOB ADDRESS AND LOC TIO _-----�-tj-!__(o_-----�r��A� Owner's Name---.�%--O�------- ��' -- ----------------------------------------------------- -------------------------------. Phone--------------------•------•--•-•--- Address..........lLl-q-------l-o --- ------- - ---------------------------------------- ------- -------------------------------------------------------------------------------------------------- Contractor's Name---- -- -' Phone_ ll--- t-- �'Z'-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---1--- Number of bedrooms _,�___ Number of baths ---r1__ Lot size _ ___________________________ Water Supply:, Public system ❑ Community system, L� Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe;Z] Hardpan ❑ Previous Application Made: Yes RL No*""New Construction: Yes lial No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i i ; r F Septic Tank: Distance from nearest well_/720 , _-Distance from foundation----/ ---___.Material_.�� No. of compartments----------Z,,----------Size------ .__Liquid depth----- -/---..---------Capacity_._. oA ' Disposal Field- Distance from nearest wel _ __Distance from foundation li--------------Distance to nearest lot line---_vr_---------- [ Number of lines________________ __._ _____Length,of each line___;?. -_-_____________--.Width of trench-_Z-_l�_-_`'-._____ __._--_____- Type of filter materiaL____ _____Depth of filter material_/_rN______-___Total length----- 3. ------------------------- S Distance to nearest welL___,!he>�___Distance from fo ndation__7JR--------Distance to nearest lot line-_ __-__--_ ® Number of pits----:-------------Lining material-_-__6&_e, _Size: Diameter__?4'K -------Depth--------- '------------------ Cesspool: Distance from nearest well--------------.-_Distance from foundation--------------------Lining material-------------------------------------- V) r ❑ Size: Diameter---------- --------------- -----------Depth-----------------'---------------------------------Liquid Capacity---------------------------gals. Privy: h Distance from nearest well________________ ___ ,________-______-____Distance from nearest building--_--__________._-__--__-_-_______-______- ❑ Distance to nearest lot line--------------------- ----------------------------------------------- - I i! k 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 ru s and reg tions of the San Joa uin Local Health District. f , -__�S._Wi % ----- ------------------------------------------ -- ----- - - --(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). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------ ---- -------------- -------------------------------------------------- --------------- DATE-------1//_1?/V_9-------------------------- REVIEWED / _1? -V -------------------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------- ------------------------------------------------------ DATE--------------------------------------- --------------------- Alterationsand/or recommendations:------------------ ------------------------------------------------------------ =-----------•--------------------•-------------------------•------------ -----•-•--------- ------------------•-------••---------------------------------------------------------------------------------•-------------- ------•-•--------------------------------------------------------- ---- ---------- ----------------------•---------- •------------------------------------•---•--•---------• -------------------------------------------------------------- ---------------- ---------- • ---------------------- --------------------------------------------------------------------- ---- -------------------------------------------------------------------•--------- -------- FINALINSPECTION 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 7.57 FRCO.