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APPLICATION FOR SANITATION PERMIT Permit No. _/'v.? _- F A 4 AV omplete in Duplicate) Date-Issued J Application•is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application ismade in compliance witCounty Ordinance [xo. 9��+ JOB ADDRESS AND OCATI N____`., - -- --- -------`- --------------- ------------ •' r 11 --- ------- Owners Name ------------ Phone.----- Address-------------------_ ---Address--------------------- �� {•{P&AY--------------------------------------------------------- Contractor's Name_ C .. ------------ ------------------------------------------------------------ Phone Installation will serve: Residence U--'—Apartment House .❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms ___�-�__ Number of baths ±f/_ Lot size ____ _ _!" _l�__"-_________________________ Water Supply: Public system ❑ Community system ❑ Private B�epth to Water Table,�-30. ` Character of soil to a depth of 3 feet: Sand ❑- Gravel ❑ Sandy Loam O'lay Loam E] Clay [] Adobe E] Hardpan ❑ M Previous Application Made: Yes E] No iso New Construction: Yes 9 ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.1/ Septic .ank: Distance from nearest weli_-5�_________Distance from foundation_"/fl__________Material_ _ ___ ___ _ _` .... .",__._._ No. of compartments_..__� .._ lF - , _ _Size_:.-�------�---_�-:---Liquid depth------�� -----------Capacity....�--'----y------- Disposal.-Field: Distance from nearest well_0..........Distance from foundatian____a_ ..........Distance to nearest lot 451- Number of lines-_3 _ _______.--"""--t -----""""--Length of each line_-- ----T__•--,------Width of trench_.;?Y_ "" " ____ ______ _________..______ A � Type of'filter material--- Depth of filter material____/_ _��____""_Total length------------ ��_ ------------- n of: Distance to nearest well_3�_ __________Distance fro foundation-,-/-4: to nearest [of line��_____------ . El Number of pits...*��-"_______.Lining material__ ___._.Size: Diameter_6K_/0.`.--__Depth_-6____1y_:._�____ Cesspool: Distance from nearest well-----------------Distance from foundation--------------.-----Lining material________"___-______.___ ❑ Size: Diameter.----------------- -------------------Depth----------------------------------------------------Liquid Capacity` ------------ gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building---------------------." -5 El Distance to nearest lot line-----------=----------------------------------------------------- Remodeling and/or repairing (describe}:__.---.----------------------------------------------------------------------------- ----------------------- -----------------------------------------------------------•-----------------I------------------------------------------------------------------------------------------------------------•----------------------------------- 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-rules and regulations of the San Joaquin Local Health District. i (Signed) ------------------ ------ ----------- --------------------------------------------------------------------(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 r APPLICATION ACCEPTED BY--- r L�'�!�------- ----------------:-------------- •----------- ----------- DATE--.--------------------�h3 REVIEWED BY ,- - DATE__.. BUILDING PERMIT ISSUED-----------------------=-=---------------------------------------------------------------------------- DATE------- Alterations and/or recommendations:---------------------------------------------------------- ---------- ----------------------------- • ---------•-----------..._ _""__-__-__-".""________"__"""""--_"_---_--__".----"-----____."-i__________.-___ ------------------------------- 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.