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-- APPLICATION FOR SANITATION PERMIT Permit No. -/U�----"--- (Complete in Duplicate) q lf� 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 'LOCATILON. _ _ --�--_-S_ �-_' ____ _ <J --------------------- C Owner's --------------------COwner's Name--------------------------1-- �t '-i 'tY � ------------------'=---- ----Y --- Phone.__ ------ Address---------------------------- ----Address---------------------------- --------5-2Y `S �� = -----------------------------------------------------Y---�-----3--------�- - Contractor's Name 4^r------•--------------------------------•_--------------------------- --------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I----- Number of bedrooms __1_____ Number of baths -------- Lot size -----9------ -!1O Water Supply:, Publics stem Community system i A , � , system.,�❑ Y Y ❑ Private Depth to Water Table ________ ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam R Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATIO_N:AND SPECIFICATIONS_ (No septic tank or`cesspool permitted if,public sewer is available ithin 200 feet.) -TM Septic Tank: Distance from nearest -----------Distance from foundation----/9-'_______.Material______ No. of compartments------�------------- Size X 3 k `' --------Liquid depth------'Y----------------Capacity Disposal Field: Distance from nearest well-.-,5Z�-------Distance;from foundation---Jq_-----------Distance to nearest lot line_$__---------- Number of lines. line Leng#h of.each line__G/O__-___-_w __---_----Width offrench-4141---------- Type of filter material_--�#�_-_______Depth of filter material_____IS_��________Total length=____-16.a._______ ---------------- Seepage Pit: Distance to nearest well ___-I---------------Distance from foundation--------------------Distance to nearest lot line----------------- Oa ❑ Number ofLining'material--____.___._ _f�- Diameter ameter_-___________.._____ ,,_ Depth--------------------------------- Cesspool: ---------- -----------------Cesspool: + Distance from nearest well-----------.___-_Distance from.foundation------------------_Lining material______-______.________--.___________- V Size: Diameter----------------------------- -------Depth I ---------------------------- ,-------Liquid Capacity----------------------------gals. / Privy- Distance from nearest well_________________ ----------------------------Distance from nearest building ----------- ❑ Distance to nearest lot line--------- --------------------------- Remodeling and/or repairing (describe):---------- .Q___- ---- ------ ------ - -.-- , --------------------------r'------a. �� .�b �' '---------- 'n'�� --------- -------------------------------------------------------------- ---------- I ---------------------------------------------- ared this application'and that the work will be done in accordance with San Joaquin County� I hereby certify that I have prep ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. , (Signed) ` --------------------- ----------- - --- --- -------- ------------------------------(Owner and/or Contractor) � F By:---------------------------------------------- -------------------------------- ------- -------- --- -- -n ----"-------------------------------- -------(Title)--------- _`__'_= -=�Y-=--------==� (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY, APPLICATION ACCEPTED BY `. ------------=------- DATE---- ---------- REVIEWED BY----------------------------------------:---------------------I--------------------------------------------------------------- DATE------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------•----------------------------------------------------------------------------------------------------------------------------••----------•------------------------------- --•-------------------------------•-----------------------•--------- ------------------------------------ ----------------------------------------------•------------------------------------- -----------------------r--------------------------------------------------------------------------------------------- - ---•-------------------------------•-------------------------------------------- - ---------------------------------- ----------------------------------------- -•----------------------------------------- ------------- FINAL INSPECTION BY_---------- ------------------------ Date------- - ---�-��--- --� ----------- .4- ---------•---- j SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-4-2M Revises 1.57 F.P.CO. _ -