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APPLICATION FOR SANITATION PERMIT Permit No. :_.� l _ (Complete in Duplicate) 3 '• Date issued ---_��___-/5_)_- 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. / 5�4h . -----------•----•--------------------------------------------------- ------- ------ JOB ADDRESS AND LOCATION__�pr-_ ___: -��.___�__ .-- Owner's Name-------- : a.5 1-�--------I -------------------------------------- Phone---- •--•-------...-•-------- Address-----------------------•------------ ------------------------------------------------------- ------------.----------- Contractor's Name-------------------------------------------------------------------------------------------•----------------------------I--------------------- Phone Installation will serve. Residence Apartment House"❑ `Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _ ._ Number of baths ---#___'Lof size,T-j3/___-/-2l-/------------------------------ Water Supply: Public systemCommunity system ElPrivate ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciay Loam ❑ Clay ❑ Adoboo Hardpan ❑ Previous Application Made: Yes E] No New Construction-. Yes A No ❑' FMA/VA: Yes ❑ No ❑ *+,,..•TYPE`OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if..public sewer is available within 200 feet.) ! Sept c Tank: Distance from nearest.well___'�---__ Distant fro foundation_____-_ -� _ Material- - - C -- ; No. of compartments-----,�--------------Size---- - - --Liquid depth----- --------------__Capacity-.- --- J_ ----• d Dispo al.Field: Distance from nearest well---_—„`_.Distance from foundation_____- ' Distance to nearest lot line_L�----------- Number ----___ __Number of lines_______ ___ __ ____.____ __ Length of each line----12_�____f 1- ___.Width of trench-_ ._ __.______._._._... } Type of filter mate rial_ W--=_Depth of filter material__ ___-___Total length____-J_ __ -._�___________________ f 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 _-.__.__.._..__----___._- ______ " El Size: Diameter--- - '---------------- --- -------Depth------------------------------------- --------------Liquid Capacity------------------------ gals. Privy Distance from nearest wef!_-__:--------------------------------------------Distance from nearest building---_------------------------------------------ ., ❑ Distance to-nearest lot line-------:_ --------, , ----------- I �1, Remodelingand/or repairing (describe):----------------------- -------------------------------•--------------------------------------------------•-------------•---------•------------- -------- --------------------------------------------------------•--=---------------------------------------------------- --------------------------------=----=-----------------------------•---•------------•-------------- - - r � -------------------------- ---- ---,-------•------ —--- ------------------ --------------------------------------------------------------------------------------------------•------------•-- ----------------- 1 1 herebycertify that I have prepared this application and ithat the work will be done in accordance with San Joaquin - Count ordinances,.State laws, and rules and regulations of the San Joaquin Local Health District. l (SiSi ned I ° ------ (Owner Contras gned) -------------- -------------------------------- (Ow and/or Contractor) I (title)--------•------------------•------------------------------------ (Plot plan, showing size of lot, location Kof system in.relation to wells, buildings, etc., can be placed on reverse side}. i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ :-::-----I----------9 ------------------------- ---- ----- --- - ----------------------------------------- PATE--------------- /r7 I---------------------- REVIEWED BY_______ --------------------------- ------l.- - ----- -.---------------------•---------------------- DATE f .----------------------------------- f BUILDING PERMIT ISSUED--------------------- -----------------------------------------------------------. DATE----- - - - Alterations and/or recomme dations:___ ___. __ ----- : =: : : ---------------- ------ __--- --- - - - ---------------U--------------------- . -- ------ . 17:4• __:k --- ------ - i_ . P ------------------ i -C --y - - -------- - - ------ R - - ------------------------------------ ---------- -- ----------------------------------------------------------------------- f �� 3 - - F FINAL INSPECTION BY:. Date' = ------------------------ SAN OAQUIN 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 r ES-9-2M , Revised 1-57 F.P.CO.