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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ----- 10.5- ____1DS-- r7,0-©-z- 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. /-rgs W1 4Wu/ 'JOB ADDRESS AND LOCA ION ---- ��Z 'c�J-�-1�Y�� ------ ----------------------------------- a Owner's Name t'—t -------.------------------- -------------------------------------------- PE�one_U_4'-[_4-2'3------ Address--- a C} -------- 4------------------------------------------------------- ----- X�111" Contractor's Name ¢ '" Phone,,�_1_-yie-2----- Installation will serve: Residence ❑ Apartment House ❑ Commercial [railer, urt ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths A___ Lot size ________________________________________-__---_-__________ Water Supply: Public system 010,Eommunify system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ["] Adobe g?`gardpan ❑ Previous Application Made: Yes ❑ No gj-'�Jew Construction: Yes gr No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if, ublic sewer is available within 200 feet.) Septic T k: Distance from nearest well_.Distance from foundation__--------Materiail ?__ ' 'w`^�' ---- --------------------- ---- No, of compartments Size_______ ./ - - nS? p -------t�----- - 1s.__`3�a-------Liquid depth - 41 -- ---------Capacity----e4P_- Disposal .ield: Distance from neares well__Distance from foundation__ ------Distance to nearest lot line_________________ Number of lines------ -------------------- ----Length of each line__&_a_` • ........ r e Type of filter material- (_( .__________Depth of filter material____-1Y-______Total length_____ �_______________________-._ 10 —•s Seepage t: Distance to nearest{{well__ _ _ ____-_Distance m f ndation___4'S`0____._..Dista�ce to nearest Cot line------ Number of pits------!.____________Lining material_ n�_-_Size: Diameter__,3-3---------- 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----------------------------------------------- ---------------------------------------------------------------------------------------------- J Remodelingand/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, a laws and rule nd regulations of the S Joaquin Local Health District. (Signed)-----. - �� `�'' — - ...................... ------------- - ............................. -- -- --------------- caner and/or Contractor) B ' ------- --(Title)- Y• r � ------ - - ----------- --- ---- plan, showing size of lot, location of sy m in relation to wells, buildings, etc., can be placed on reverse side). OR ARTMENT USE ONLY APPLICATION ACCEPTED BY --------------- ---------------------------------------- DATE-------J Q •� REVIEWED BY------------------------------------------------ DATE--------------------- BUILDING PERMIT ISSUED------------------------------------=--------------------------------------------------- --- --------- DATE Alterations and/or recommendations:---------------------------------------- - ---- -•------------------------------------------------------ --------------•--------------------- -••------------- ----------------------------------------------------------------------------------------- ----------- ----------------------------------------------------------------------------------------------------------------------- -----------------------•------------------------- -------------------------------------------------------------------------------------------------------------•------------------------------------------------------------ -----------------------------------------------------------.-------- --------------------------------------------------------------------------------------- ------------------------------------- --------------------- FINAL INSPECTION BY:_____-_ _ _ ---- Date__.___ -- - ;----------- ---------•----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1-57 F.P.C.O.