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Permit No. ---/ �D APPLICATION FOR SANITATION PERMIT ; in Duplicate) .M• (Complete Date Issued ---- :T- Application �. -_.- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i.1 y This application is made in compliance with County Ordinance No. 549. ----- •-----------•-------------------------------- 1 JOB ADDRESS AND L ATI N-__,_-- -��--------- -- Phone--------------------•--------------- Owner's Name---------- ------------------ Owner's Name .4 Q------rs------• -------------------------------------------------------------------------------------------------••-------------------------------------- - ----------- Phone.- ---•--------- Contractor's Name----------------------- ----- - -------- Installation will serve: Residence [JJ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --/-- Number of bedrooms __/-__ Number of baths ___�- Lot size ____ ._ Water Supply: Public system [Community system El Private C] Depth to Water Table '/ ft. Character of soil to a depth of 3 feet: Sand [jGravel [] Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe [Hardpan ❑ Previous Application Made: Yes [INo ,❑ New Construction: Yes E] No �HA/VA: Yes ❑ No El TYPE OF INSTALLATION AND SPECIFICATIONS: a. (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) S tic Tank: Distance from nearest well-----------------Distance from foundation------------------- c No. of compartments---- ---- -------------Size_-----•-------------------------Liquid depth--------------- ----------Capacity pispasai field: Distance from nearest well-Distance from foundation-___la---------Distance to nearest lot lie____ __________ , ❑/ Number of lines_---------1----------- -Length of each line------ a- Width of trench---- ---------------- Type of filter material_Sr_, ---Depth of filter material__-_-.lfl'.------.Total length_____A�Q_'------------- Seepage Pit: Distance to nearest well_____________________Distance from foundation-------------.------Distance to nearest lot line__._______--__._ ❑ Depth------------------------------- Number of pits_________________----Lining material______--_.__--___-----Size: Diameter------------------------ Cesspool: Distance from nearest well-_-_-________--_Distance from foundation--------------------Lining material [-I -----De th---------------------------------------------------Liquid Capacity----------------------------gals. Size: Diameter____-_----------------------- - P /►n Privy: Distance from nearest well-------------------------------- --------- --___.Distance from nearest building------------------------------------------ \!1 r ❑ Distance to nearest lot line---------------------- - --------------------------•---------- ------------------------------------------ l t 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 an regulation the San Joaquin Local Health District. -� -----------(Owner and/or Contractor( Si ned ---- Tile ---- --- ------------------------------------------ t i (plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side(. ' FOR DEPARTMENT USE ONLY ' DATE----- -------------------------- APPLICATION ACCEPTED BY------f 'R__a1--------------- ------------------------ REVIEWED BY---------------------------------------------------- - ---------- --------- ----------- ---------------------- --------- DATE------------•---------------------------------------------- BUILDING PERMIT ISSUED-------------------------- -- l~ DATE Alterations and/or recommendations:-- ----- 4 [� -1'c� _ T Q.F A_ l-l-----------Q4%------------------•---------------------- -- -------- n-------------------------------------------------------------------------------------------------------------- ------------------------ ------ --- ---------- -- --- --------------- ---------- --------- ---------------- -- --- ---------.------------------- ------------------------ - -- -- ------------------- ------ f----------------- 1 Date----/ FINAL INSPECTI BY•----- ` Y-- ---------------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CO.