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P ]CATION FOR SANITATION PERMIT Permit No. f1 J (Compete in Duplicate)liI Date -l..suesd Pcate ------�------�, Applications made to an Joaquin Local Health District for a permit to construct and install the work herein described. This application is ma a in compliance with County Ordinance No. 549. yy - JOB ADDRESS AND LOCATION----- ------ --- �-'------------��+��/- -��-- ------------------•-------- 4/0 ---------------- Phone-/ `S Owner's Name-------------4 .- Address------ �� {-------- f� -� ( Ca Contractor's ame- l Phone �� soT'� --------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑-- Motel ❑ Other ❑ Z) Number of living units: _ _-•Number of bedrooms =____-_. umber of baths __ -___ Lot size _:__ ___ _ Water Supply: Public system Community system ElPrivate ❑ D-epth to Water Tableft.' Character of soil to a depth of 3 feet: Sand ❑ [jGravel • Sandy Loam'❑ Clay Loam ❑ Clay E] Adobe ardpan ❑ C�,. Previous Application Made: Yes F1No ew Construction: Yes ❑ No [j _F_HA7(VA: Yes [INo -y TYPE OF INSTALLATION AND SPECIFICATIONS: ,I -4 (No septic tank or cesspool permitted if public sewer is available within 200 feet.] ; Septic Tank^ Distance from nearest well----------------- from foundation__________________-Material'____---_____________.__-__________.._.___-____.4 No. of compartments-------------------- -----Size---•----------------------------Liquid depth` *-----------------.-Capacity-------- ------------ Disp I Field- Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line__ _--_-_-----1. -.*vYNumber of lines-----------------------------------Length of each;line------------------------------Width of trench-- -___Jy------------------------ Type of filter material________________________Depth of filter material-________----__ ----- ____Total length----3_e___--______________-_r_-_-- Seepage✓Pit: Distance to nearest w IL.._ -----------------Distance from foundation---�d_____.___.Distance to nearest lot line__.-__-__._. [� Number of pits-------- _- --Lining material_/ _�!' ize: Diameter----Ju?-��-------Depth---- -s- ---------------- _*4 f 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 _------------------ ----------- � � X17 F ---------------------------•------------------------ -----------------------------------------------------------------------------------------------------------------------------------•-- 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 pan regulat' of the San Jo uin Local Healt istrict.r - ---_----- ----------- (Signed) -�.!w"'"�' r2 1-------- (Owner a d/or Contractor) --- - -----------BY:-------------------- - -- ----- -------- ----- ---------� (Title) ------------------------ (Plotplan, showi g s e of lot, ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ---------- -- ----------------- DATE------- ----- d - --------------- DATE--------------- --�--------- - -------------- REVIEWEDBY------------- -------------------------=------------ - � ------•----- ------------ ------------- ------ - - BUILDINGPERMIT ISSUED--------------------------------- ------------- -- DATE------------------------------------------------------------- Alterations and/or recommendations:-------------------------------------------- --------------------------------- --------------------------------------- t _ ---------- ----- --------------------------------- - ------ ------- S --------------------------- - tA ------- ---------------- - -- - ---- -- - --- --- ------- -------------- -- - t FINAL INSPECTiON BY:_.__ Date--- r----'- -----------=------------------- t SAN JOAQUIN LO L HEALTH DISTRICT ? 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Y Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P.CD.