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! APPLICATION FOR SANITATION PERMIT Permit No. ._ ----------- 1 (Complete in Duplicate) j�� �l 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 CountyO:r inanceNp. 549- JOB ADDRESS A LOCeTIO - --- _._._- =-- ---._... ------------------- - ---- -------- ----------• k . Owners Name •-----=-----•------------------ ----------------------------' ' Phone -- - -- -- Address------ --- ---- !! -------------= =- :.: ----------------------- -------.- f� -- _ zP ' Contractor's Name___ - # Phone ____ Installation will serve: Residence [Apartment House ❑ r Commercial E], -Trailer Court-❑ Mtil ❑ Othe�--❑ ---------- Number of living units: ___�__ umber of bedrooms J--- Number of baths ._I___ Lot size --- re_ j -- -- -------- ;I - -- ---- Water Supply: Public system Lwj Community system ❑ • Private ❑ Depth to Water Table --" -- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ElClay ❑ Adobe Hardpan ❑ a Previous Application Mader .Yes ❑ No [] New Construction: Yes ❑ No ❑ FHA/VA:,Yes ❑ No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitfe public seMer is available within 200 feet.)f ' + Septic ank: Distance from ne,,est w�e�� _' C Uista cel fro foundation_______ _________ atfe,�i l________- "` _._:_- _ - Li uid e th_ ________ Ca acit _ r No_ of compartments - ize 1- -- -------- �--- •- q � A I p Y- i � 'Dispos 1' FieldDistance from nearest w II Qistance from foundation4-0). Distance to nearest lot liNumber of lines---------- -•-- - Length of each line------_-- - - ---.Width of trench`---z_/ '7�_______________- 1 Type of-filter material _.----,____ epth of'Filter materiai_____ . __._Total length* ___ _ ____________________ Seepage Pit: Distance to nearest well------------------- from foundation------------.-------Distance to nearest lot line____'___.__-___ I ❑ Number of pits----------------------Lining material------------------------Size: Diameter------------------------Depth-------------------:- Cesspool: Distance fi.om nearest well---------------{_Distance from foundation--------------..__..Lining material-------------------------------------- ❑ Size: Diameter- -------------------------- Depth--------------- --- -------I---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well____ _ ------------------------------ -------------Distance from nearest building------------------------------ __._____-- ❑ Distance to nearest lot line__^:_________________ -__________- - Remodeling and/or repairing (describe):- -------------- --=--------- r---------=---•-----�--------------------------------------- --------------------._... = �. -----------------------------------------------------•---•--•------------------=----------------------- -•--•-------------;----------------------------•--------------------------------------------------------------- --------------•----------------------------------------------------=------------------------------------------------------------------ -•---------- ----------------------------- I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin County ordinances, State s, and rules and regulations of the San Joaquin Local Health District. I (Signed)----4 - - e- -*�,' �� ? = - = ------------------(Owner and/or Contractor) f - --------------------(Title)-- ------------------------- (Plot plan, showing size of lot, 16cation'of system in relation to wells, buildings, etc., can be placed on reverse side). ( FOR DEPARTMENT USE ONLY + f APPLICATION ACCEPTEb BY DATE-6 D 2 REVIEWED DIIVG PERMIT ISSUED _ ' ---- -- ---- ---------------------------- DATE- BUIL Alterationsand/or.recommendations------------------ ------------------------ ' --=-----•-•--------------------------------------------•------•---------- -------------------------•--•-•-- ----------------------------------`---------------- - -------- ---- -=--------------------f----•-•-•-----------------------•---•------------••---••---------------------------------- --- ----------------- -d'z-,C FINAL INSPECTION BY:._ t---W-9-------------- .. Date.-./A---------d�---"--�_L- ar-------7-----------------------------= SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Stre,ef Stockton, California Lodi, California Manteca, California Tracy, California i . i ES-9-2M , Revisecs 1.57 f.P.CO.