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3 APPLICATION FOR SANITATION PERMIT Permit No. .......`............. r (Complete in Duplicate) �j5 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 application is made in comp li ce with County Ordinan e No. 549. ---------------------- JOB ADDRESS AN LO*_. .-��V-••------ --- - ------•--•-------- --------- Owner's Name ---------------------------•---- ... Phone------------------------------ -- ---------- Address-----------------� ----- ---------- Y --------------------------------------------•-•---------------•-------------•------ Contractor's Name-------------------------------- Installation ---------------`-f------ Phone Installation will serve: Residence ❑ Apartment House �mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _'3---- Number of bedrooms --f- Number of baths -------- Lot size ---OX-1�0-------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -1t477ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ ' Previous Application Made: Yes ❑ No VNew Construction: Yes ❑ No [ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---_--------.---Distance from foundation-------------------Materiai---------------.--------------------------------- ` ❑ i, No. of compartments--------------------------Size--------------------------------Liquid depth---------------- -----.---Capacity--•-------------------- . Disposal Field: Distance from nearest well ---_--.-..--- Distance from foundation--------------------Distance to nearest lot line-------------_- 171 Number of lines---------------------- ------------Length of each line-----------------------------.Width of trench-------------- •------- --------- Type of filter material-------------------------Depth of filter material-----------------------Total length.---_---------_-----------_----�------- Seepage Pit: Distance to nearest well--- �-----.---Distance from foundation__/Q_--_--_-_-..Dista�? to nearest lot line---- -_�__._ q Linin material----- Diameter----as------ ----Depth____-..- Number of pits. �-------------- g C �------------------- 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------------------------------.------ ❑ Distance to nearest lot line-- ----------------------- ---------------------------------------------- Remodeling and/or repairing (describe):_----------------------------------------------------------------------------------------------------------------------------------------------•------- -------- --------------•--------------------------------•------ -----------------------------------------------------------.-----•------ ----- -- -------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------- 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 -'=-------------------------------------------------------- -----(Owner and/or Contractor) BY �--------------------------------------------- =---Y--------- ------------------ ---------------------------------------------Titl --------------------------- ---- ---------- ------ (Piot 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----. w_d------------------------------------------------------------------- DATE ---- ----------------- REVIEWEDBY-------------------------------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------.---- BUILDINGPERMIT ISSUED---------- --------------------------------------------------- ------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations-------- -- --------------- ---- -----------•----------------------------------------------------- -------'---------------------•------------------------------,---------- ----- -------•----------•------------------------------------------------ ----------------------------- ------ _ FINAL INSPECTION BY:..- ----y------ vim--` Date ` �- SAN JOAQUIN LOCAL HEALTH DISTRICT l3o South American Street Soo West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1 ES-9-2M Revised 8-'59 F.P.Co.