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w A APPLICATION FOR SANITATION PERMIT Permit No.......j __J.._./ (Complete in Duplicate( • This Permit Expires 1 Year From Date Issued 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 a plication is made, in compliance with County Ordinance No. 549. JOB ADDRESS AND LOC ION------- -�- --e .. L J 0I � ,A 11Y e/✓ ---------------------------------- Owner's ----------------------------Owner's Name _"/-5------- ------------------------ --- ------ ---- Phone --- // a--'7�elrM Address ----------------------------------- Ezj5�r4e_1-+e . ------------- -----------------•-------- Phone ----------------------------------- Installation Name ------ ------------ s�f----------------------------------------------- ------------------ - - Installation will serve: Residence K Apartment House [❑ Commercial ❑ Trailer Court ❑ Motel E❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size.--__--_______-------------------------------------------- Water Supply: Public system ❑ Community system ❑ Private ;K Depth to Water Table a -Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam j$ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No X New ConsfructioW.- Yes ❑ No 0 FHA/VA: Yes ❑ No 25 TYPE OF INSTALLATION AND SPECIFICATIONS: 4` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest w61__,_570*"__ Distance from foundation ------ Q -_-_____. Material ---do•U.---___ _ �( No. of compartments--. -------- a ------- Size._,,5___s __2-__Jt_`� —Liquid dep. h----- - -___-------- Capacity_----__��Q-- Disposal Field: Distance from nearest weil__.7-d --- -__ Distance from foundation _ -_-1'Q--- ---Distance to nearest lot Number of lines --------------- 1-#_ ----------- Length of each line ------------- $---_.Width of french ---------- ;W.----- Te of filter material___-. - n _---.-.___-_-- Type r& -------Depth of filter material -------- length ---------,a_-9- ------------------ Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------------------- Distance to nearest lot line ----------------_ ❑ Number of pits---------------------- Lining material ------ ----------------- Size: Diameter----------------------- Depth_ ---- ---------------------------- Cesspool: Distance from nearest well -----------------Distance from foundation -_-_-____-__------.Lining material-_---------------------------_-------. ❑ Size: Diameter -------------------------------------- De th------------------------------------------Li uid Ca acit p- - q p Y - --------------------------gals. Privy: Distance from nearest well ---------------------------------------- ------Distance from nearest building ----____----------_---_--------_-_--_--- C ❑ Distance to nearest lot line------------------------------------------------------•----------------- 9 an/ r6 Remodeling and/or repairing (describe): - w- p g ( ) �-�-�---�it'----- ------------•---•-------------• •-------------------------------------------•--•--------------- -------------------------------------------------------------------------- ----------------------------------------------------- -- ----- ------------------- ------------------------------------------------------ ----------- -------------------------------------------- ---------------------------- ------------------------------------- -------*_- I -- I hereby certify that 1 ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, fes a d r "o of the Sart Joaquin Local Health District. (Signed) - --------- - I (�nd/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 APPLICATION ACCEPTED BY /1' x , -------------------- DATE_. `-3 = - REVIEWEDBY ------------------------------- ---------------------------------- DATE ------------------------------ BUILDING PERMIT ISSUED--------------•-----------------------------•-----------------------------------------•--------- ---- DATE -------------------------- Alterations and/or recommendations---------------------------------------------------•------------------------------------------------------ -1 --------------------------------------------------- ------------------------- -•-----------------•-----------•----------------------------------------------------------------------------------------------------------- -------------------•----------------------------------•-------------•---------- .------------------------------------------------------------------------ --------------------- FINAL INSPECTION BY: --`Q ------ �-- �-------------------- Date----------- -- --c�-- --- - - 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 8-'59 F, P, Co.