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v• , ✓F APPLICATION FOR' SANITATION PERMIT Permit No. gds 5_______ {Complete in Duplicate) rj Date Issued ___ 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. JOB ADDRESS AND ---------------------------- - LOCATION ' �--h - Phone Owner's Name____ / d, -------- ss ------ ssAddre — ---------------- ----•-----••-------•------------------- , Contractor`s Name--- ! ----------------------- Phone----•--- _-- -------- ---------------------------- - --------- Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-4-- Number of bedrooms _J�Number of baths -07-- Lot size_ (___- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table �47t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R?-17ardpan ❑ a Previous Application Made: Yes ❑ No ZR,"New Construction: Yes ❑ No FHA/VA: Yes ❑ No 2 -- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from nearest well-- _Distance from fo dation_~? -__--Mat�rial______________ _ __ j o� - ---------------- No. of com artmerits____ _ ` _-Liquid de th_�___------_ Capacity p �C----------------Size ' �l� � q � f�7�_ Disposal Field: Distance from near t well_ _ Distance from foundation__�0----/ Distance to nearest lot line____..__. Number of lines--- --------- -_ Length of each line- �- ___ �f '� s' -------.Width of trench--- = Type of filter material ___ Depth of filter material_ ________Total length----��1.`___ ______________________ Seepage Pit: Distance to nearest ,, Distance rom fo dation-----------------___Distance to nearest lot line---------- _ Number of pits___-%,%-------------Lining materiae . -Size: Diameter_zPZ:F1_/!------Depth___Ae_ Cesspool: D•stance from nearest well_________________Distance from foundation_ ___________...___.Lining material___.__.__.________.________-___-_. �] Size: Diameter--------------------------------------Depth----------------------------------- -------------Liqui.d Capacity----------------------------gals, 'Privy: Distance from nearest welf---------------_____________________________r--Distance from nearest building_=__._,___.____,--------------- ,_ ❑ Distance to nearest lot line----.______-------------- Remodeling andrepairing (describe):____--__.. ---------------------------- •r----- ----------- •------------ •-- t 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 regulations of the San Joaquin Local Health.District. -------•----------------- . r-contractor} By:------------------------------ �� '� ------------------------------------------------------(Title `-' --�. ---. ..`----- (Piot plan, showing size of , location of system in relation to wells, buildings, etc., can be placed o i reverse e). I FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------------------- ----.----------- ---------------------------------------- DATE-------------- 1 �}.--.----------------- REVIEWEDBY----------------------------------------------------- -- ------- --------------------- ------------------------- DATE--------------- ---------- /I---------' BUILDING PERMIT ISSUED--_----------------- --- --- -----------------•------------------------------------ -• DATE Alterationsand/or recommendations:------ --- -- ------- - ----------------•--•--------------------•-- -------------------- ---------------------------------- ------••---------- ------------------------------------------------7............ -------- ---------•-----------------------------•------------------.._......._.-------- ---- ---------------------------------------................................................. ...................................................... -- t -------•---• -------------------------- -----------------------•--------_----•-------------------------•------------------------------------------------------•----------------------------------------------- ------ FINAL INSPECTION BY:._ Date SAN JOAQUIN'COCAL 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 i ` ES-9-2M , Revised 1.57 F.P,CO. ;