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APPLICATION FOR SANITATION PERMIT Permit Nb. ' (Complete in Duplicate) Date Issued ---------lirl Application is here made to the San{Joaquin Local Helk District for a permit to construct and install the work herein described. This application is made in compliances with County Ordinance No. 549. JOB ADDRESS AND LOCATION,...-'J ------- . ---------------------------------------------------------------------------------------- Owner's Name G.�1F.�`. --•----'�------ 1�-f ----------------- Phone---o - Ph,ne ' yam------------------------------------------------- Contractor's Name--------•----------- ------------------------------- Phone_.. Installation will serve: Residence� Apartment House —"C�mrnerciaf ❑ Trailer Court ❑ Motel ❑ Other ❑ x! Number of,living units: __ __ Number of bedrooms j-__- Number of baths ---f--- Lot size __ ___ - "_ -"' --- -----------.------ ` Water Supply: Public system ❑ Community system fl Private 4 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ] Hardpan ❑.� Previous Application Made: Yes ❑ No,9,, New Construction: Yes No ❑ ` r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pei-rnitted if public sewer is available within 200 feet.) Septic Tank:. Distance from nearest well__-----Distance from founda ion____'`a_--___-Materi I_.--C.C��-�(�w-___- ---_-..--. No. of compartments----------)—- ------Size--?-_�.-�_1 Liquid depth----------- ---------Capacity__-- " � Disposal Field: Distance from nearest well---X* ----Distance from foundation1_Q__.-- .Distance to nearest lot line..... "__r___ Number of lines____-_- -_ __-�,---_-_-__ ength of each line-----__:_---- > I_---Width of trench_____-.-__ - Type of filter matenal_±�_Vsr__�--a4-pepth of filter material-------/-p----------Total length_--_----___-7- -----------------t-- Seepage Pit: Distance to nearest well-----------------__--Distance from foundation--------------------Distance to nearest lot-line------------------ ❑ Number of pits----------------------Lining material---------------------- Size: Diameter------------------------Dept h------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- El --_------------ _-----____._-_---_❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------ ------------------ ------Distance from nearest building-------------------------- .-•----------. ❑ Distance to nearest lot line----------------- ------------------------------------------ ---------------------•----------------------- --------------------------------- Remodeling and/or repairing '(describe)------------------- ----------------------•------- ---------- -----------------• ------------------ -------•------------------------------•-------------------- ---------------------- -----------=------ -------•----------- -------------------------------- a _ ` I 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. (Signed)_ _ r 4 _______________ ___ ___ (Owner and/or Contractor) .►.�• (Title) BY:--- (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 APPLICATION ACCEPTED BY--------=---------- ---- - ----- DATE- REVIEWED $Y-------------------------------- ------------- ---------------- ----- ---------- ----------------- DATE-------------------------- ----- -- -- ----- ------------------- ;r BUILDINGPERMIT ISSUED--------------------------------------------------------------------------- ------------------------- DATE-- ---------------------------------------------------------- Alt ation% and/or racon pndations:---------- ----------------------------- ------------•-- ----------- - ------------------------ -------------- ---- -�- ---- _ _: ----=-- - ----------------------------- 1 - _ _ ----------------- A. s:_- ----------------------------- ---_--- --------`---------- l --- !� � -s��k A-A- j-------- r_- ` -— -'---. FINALINSPECTION BY-------------- I--- -------------------------------------------- Date---------------------------------------`-{ - ----'----------- I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 1 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California a Lodi, California Manteca, California Tracy, California E5-9-2M 8-51 Revised W-2100