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APPLICATION FOR SANITATION PERMIT Permit No. p (Complete in Duplicate) W 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION____-X-Faf'% � _,�I` ------------------------------- ----------------------------------------------------------- Owner's Name_ �• l 'r---------------------------- --- ------------------------- Phone---------•----------------------•--- { Address---------- Contractor's Name ✓1* —-------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ __ Number of baths __l__ Lot size __ � Number of living units: _____.__ Number of bedrooms _ ______�_,__,�f�Q__ ________________________ i Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table 00- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made- Yes ❑ No P— New Construction: Yes ❑ No [Er''I=HA/VA: Yes ❑ No RP-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tapk: Distance from nearest well_________________Distance from foundation---------.__.-------Material_________________________-____--------_________- GX�� No. of compartments----------- ------- ----Size--------------------------------Liquid depth---------------- ---------Capacity----------------------- Disposal Field: Distance from nearest well-------- __Distance from foundation----A0_�----Distance to nearest lot line.zO_____�____ yy�t//�� Number of lines_____-_�____- - Length of each line____ • __ }} g ��- ------------Width of trench._-,�- _-�� 4✓1 , Type of filter material_ k�/[r Depth of filter material_____, 110�-_Total length_______-?. _____________________ Seepp/agge Pit: �istance to nearest well____ ..____Distance f,rr� fou daticn___� ._�__.Di t nce to nearest lot line ----------- 0a X`�]�J'�sad of pits_--._..________Lining material___ L,��j t.Size: Diameter___ ��.___-_Depth___A%.;F-''___________ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material-------._._.__..____.____ ❑ Size: Diameter------------------- -----Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______-__._____________________.___-_. ❑ Distance to nearest lot line------------------------------------------------------------------------------------- Remodeling and/or repairing f(describe}_---_______________________ f/j --------------------------------------------------;---------------------------------------------------------------------------------------------------------------------•------------------------------------------------ I hereby certify that I have prepared this ap'plication and that the work will be done in accordance with San Joaquin•Counfy ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, (Signed) -----------------(Qwwe Ler Contractor) By: - -- - - -------------------------------------(Title)-----�/1 ----------------- (Plot plan, showing size of lot, locatio system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- [, ------------------------------------------------------------------------------- DATE--------5=it`- --•- ----------------------------- REVIEWEDBY------------------------------------------------------------------------------ --------------------------------------------- DATE----------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendafions:------------• ----------- -----------------------f---------------------------------------------------------------------------------------------------------- --------------------------- ------Pl-T----__-D -----------!.Z5--------------- Ft�s�r-r ,FEACI-,+ �-: 044< F 'r1kc,--------------------------------------------------------- --------------------------------------- --------------------------- FINAL INSPECTION $Y:.- { Date---------------J� { 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 i ES-9-2M Revised 1-57 F.P.CO.