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S ; 1 APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date ]slued _��1s 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. l W&02 , sum 1 � c1 � sp�,�i, �.� ��ds�4� JOB ADDRESS AND L CATION_._- - -- --- ---- -6 -�,!„ -1 _- S � ,-- Owner's Name---- ----------------- 7 1 t� – i1'70'��„------------------------------------------ Phone Address-------------------•�`� .. -- - - - -- - -- - Contractor's Name - ---------------•-------------------- -------------------. Phone. - -------------------------------------------- ---------- Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1---- Number of bedrooms __1---- Number of baths _,(----- Lot size _---I� - --� Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table –)-f( ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Applica+ion Made: Yes ❑ No, New 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-----LO--------Material -. ---------------- ,�C. tf { -•_ -- No. of compartments-----�- -----Size__'-_Y-,`C,-S j--------Liquid depth---------------------Capacity--- Disposal Field: Distance from nearest well--.Zb_--_.Distance from foundation__`__1_T2---------Distance to nearest lot line- Number of lines-------- t- _- -_-_ --- --------- Length of each line------- -j-- ---------- Width of trenchp.----.� ------------------_-- Type of fitter material-- -�_,_aDepth of filter material-----_} --____---_.-Total length_--_-C� b- i 10 Seepage Pit: Distance fo nearest well-------------- ----Distance from foundation-------------_----Distance to nearest lot line-----------------. ❑ Number of pits----------------------Lining material---------------------- Size: Diameter-----------------------Depth---------------------------- 6 Cesspool: Distance.from nearest well-----------------Distance from foundation-=__'------.------.Lining material-------------------------------------- E] Size: Diameter De th-- --------'---------/--------------Liquid CapacitY----------------------------gals. LV) _ Privy: Distance`-from nearest well-_---------------------- ----------------------Distance from nearest building ❑ Distance to nearest,lot'line_-------------------------------------- -- -- --------------------------------- Lrj Remodeling and/or repairing (describe):---_ =-------------------------------------------------------- n -----------------------------------------------•------------------------------ a ----------------------------------------- = -------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------- } I hereby certify that'll have prepared Ais application and that the work will be done in accordance with San Joaquin County Q. ordinances, State laws and rules and regulations of the San Joaquin Local Health District. (Signed)_ I(� t V - •:�_ _ ---- ----- - --------- ---------------------------------------------------(Owner and/or Contractor) Y By--------------------------- -------------------•-- ------- - - ----- - -- ' - - -- - - - - -- ------------ - - -- - - -------iTi+lel----------------------------- ----------- M (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 .-Y APPLICATION ACCEPTED BY------------------ -------- ------ --------------------------------------------------------------- DATE------ --------- --------------------------------- VIEWED BY - ----------------------------- DATE ----------------- -- UILDING PERMIT ISSUED------------------.-----___----- -- DATE---_------------------------------------------------------------------ AI#erations and/or recommendations: V --- -- -- ---- --------------------------•------ ----•------------•- ------------ . -------------------------- --- ------------------- .� L ------------ ------------ ---- - -- -- ------------------- - ---- _ •--------- ----- -- - ` ----- --- --- 4---�- -----r BY-------------- ---- ---- ------------------------------------ -- Date--------f�--r--- - = SAN JOAQUIN LOCAL HEALTH DISTRICT X130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California \ r ES-9-21x1 Revised 1-57 F.P.CO.