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APPLICATION FOR SANITATION PERMIT Permit No. -_`�-3__: -S_-- 1� (Complete in Duplicate) Date Issued l© r - /S'd �r 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 LOCATION-- Zf--- --• - - = ...._ Owner's Name------. r --------- ------------ ------------------------------------------------------ Phone----------------------------------- Address---------- ------ -------- ------- C Contractor's Name-------- --� = Phone Installation will serve: Residence R��Apartmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E❑ Number of living units: _ __ Number of bedroomP_ _ Number of'baths /:__ Lot size __1__ _________________________________ Wa+er Supply: Public system ❑ Community system ❑ Private,pn"bepth to Water Table f`/__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑,- Previous Application Made: Yes ❑ No New Construction: Yes:Er No ❑ FHA/VA: Yes F��o ❑ W TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) r�1 Septic Tank: Distance from nearest ___Distance rom foundation_--.60--------.Material Gam__ __ _ ... __ ___._. No. of compartments --__- __ --Liquid depth___lf_�__ Capacity._r��10------ line -10 UR� p s i f Disposal Field: Distance from nearest well._l.'o---_._.Distance from'.foundatio�____ ` �� r _______.Distance to nearesot line_ Number of lines__________._! aength of each line--- ___`_,_______.Width of trench____ __�______________________Type of filter material-/- epth of filter material-_/ ______.____Total length------ _ -.c `_____- • S " J Seepage Pit: Distance to nearest well---- -------- lance fr m fours tion___. __ __..Dist�nr e to nearest lot line____.__--. i � Number of pit .... Lining material 411ize: biameter �_____________Depth__: _ _'______________ 3 1 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--------=::---= – _ =`--------------=" `--------•----------------- w _ f Remodeling and/or repairing (describe):------ /� . ---- -- -- --------------------------------•----- - = -------• - -------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------=----------------------------------------- ` ,1 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 and re ulations of the San Joaquin Locall Health District. dnop (Signed)-- By:-------------------------------------- ------►----------------------------------------(Title}- - ------------ •---------------- (Plot plan, showing size of lot, tion of system in relation +o wells, buildings,'e+c., can be placed on raver side). s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE � t �- - REVIEWEDBY------------------------------------------ -- ---------------- ------------------------------------------------- DATE-------------------------------------------•-•-------•- { BUILDING PERMIT ISSUED----------- ------ ------- DATE-------------------------------- - �dations------------------------------------------------ ------------------------- ----------- =-------- Alterations and/or recomme T ---------------------------------------------------------------� rf C r c'-rte------- 1{- 'r, -----�' --------- 5----------------------------------------- -------------------------------------------------1 -----A_A_ - ;71 - ----._I-ee-I.------------•--------------------------------------------------_-.-------------------- 1 � � FINAL INSPECTION BY------------- = U_ e�------------------------- Date------------ -- --------- N r---N 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 t ES-9-2M , Revised 1.57 F.P.Co.