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vUb 4 1 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --- This Permit Expires 1 Year From 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. y JOB ADDRESS AND L CATION--- ------------ - -- = fit--~} f'-.. ` '- --------� lJ/ ------------------ ------------------------- Owner's Nam ------ -- - ----- = ------------------------- ------------------------------------ Phone-----------------------_----- Address ------------� ----- - -•- ------ ---- -- - ------------------------------------------------------------------------------- ! r 1. 1 Contractors Name---------------- --;,�/r�u;,�:,.::----- .- ----- Phone.......•----------•------- Installation will serve: Residence , Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms Number of baths ._ __ Lot size /-- _ l-�-----,�K -----... Water Supply: Public system J9 Community system ❑ Private ❑ Depth to Water Table -------- ft. ` Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciay Loam ❑ Clay ❑ Adobe.j Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ElFHA/VA: Yes ElNo ElTYPE OF INSTALLATION AND SPECIFICATIONS:,, (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � Septic Tank: Distance from nearest well---3_�_____Distance from foundation__._f r______.Material____._._l No. of compartments--___.___.-�'-------_Size--- : Liquid uid de th____ f - ---------Capacity----6-- -4;---- Disposal Field: Distance from nearest well..... .._.Distance from foundation----- �.*......Distance to nearest lot.0 line-----s.- Number of lines______________ __. .___ Length of each line____.___________=_.Width of trench.___ ..______._.___....__.___ Type of filter material._____ � __Depth of filter material---f_?�--------- otal length_____________/__i__r�__.�-_.,�___�__� Seepage Pit: Distance to nearest well------: -____Distance from foundation-----6�.-------Distance to nearest lot line__.____:__ r , • CAI Number of pits------,f------------Lining. material_____-;4`'�'�_ "....Size: Diameter_.___. ------------Depth_. 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 alws, and rules and re tions f the San Joaquin Local Health.District. {Signed�ppan, --- -------------------- - ----------- _ _ {Owner and/or Contractor] ------------------------------- --------- ---------------------------- --- -- - --------{Title} — - • f ti. �-�� --- ---------------------------- --------- (Plot showing size,"of tot, la Ion of system Wrelafion to wells, buildings, etc., can be placed -on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- DATE-- ------ ----- ----.---------------------------------- REVIEWEDBY------ ------------------------------------- DATE----•- � r1- -----------------------•--- ------ BUILDING PERMIT ISSUED___________________ .__- - - ------------------------------------------------------------------- DATE-------------- ----------------------------------------------- Alterations and/or recommendations:.----- _____-_-_ :_-_ -----------------------------" ----------- ------P------- -• -----------.--.--- .1F___� :�_ :_:__ ____________________________________________ -- --------------- FINAL INSPECTION BY:.--------- ----------- - - --------------- ----------- Date----------,--`---- ---------------------------------------------- =, SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+rest 300 Wes+ Oak Street 132 Sycamore Sfree+ 814 North "C" Street Stockton. California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 P.P.Co. f#