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3 Permit No. _f�----------- (Complete _ APPLICATION FOR SANITATION PERMIT - -- 1 Sb (Complete in Duplicate) y{ _,S -j Date Issued ----- A Application is hereby made to the San Joaquin Locai Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. ; p �8 JOB ADDRESS AND�CATI � ��.�-��_ ___ J, , ---------- Phone------- ---------------- Owners Name------------ {---• -r------- 1.��----�-�•�-_�--- --------- --------------- ------ _ Address-----------•---------------------• r.t%°- =-------------------------------------------•------- --------------- Contractor's ------------ {{ I E 'Y Contractor's "Name t - �f •--------------------------- Phone ; Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms -3__:_ Number of baths _Z—. Lot ---------------- _______ Water Supply: Public system ❑ Community system ❑ Private ❑' Depth to Water.Table —----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam e Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application 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.) �j Septic Tank: Distance from nearest well ----- &-9— -__-_Distance from foundation__-�Q_______._.Material______________________________________ No. of compartments_____.___ __%__._Size__ ��_' ±_C/ -___Liquid depth__.___-_ --------------- Capacity._fl�__��_. Disposal Field: Distance from nearest well__5Q------- Distance -from foundation _-__,/4__�-.Distance to nearest lot line ----- b r____ ap Number of lines ------- 3___________ Length.of each line___Width of trench..___ `_ �__.__ Gj -- --- F ' Type of filter material_ �_��;. Depth of filter material --- ;,�____________Total length_______„1_� �_________________ a Seepage Pit: Distance to nearest well__ -__.::______________Distance from foundation ____________-..____.Distance to nearest lot line ----------------- 0 Number of pits ------ ---------------- Lining material ---------- ------------.Size: Diameter ------------------------ Depth -------•------------------.--••-- Cesspool: Distance from nearest well_________________ Distance from foundation --------- ---------- .Lining material ____.___.------------- .---_-______- ❑ Size: Diameter De•pth--------------------------- -Liquid Capacity ---------------------------- gals. Privy Distance from nearest well_______________ __-------------- _--------------- Distance from nearest bui4cling ------------------------------------------ ElDistance to nearest lot line---------- ---------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe}-------------------------------------------------------------------- -----•-------------------•----•-----------•-------•---- •---------------•-------- F ________________________________________________________________________________________________________________________________________________________________________________________________ f __________________________________ _-___.____________________-.-.__________________._...________________.___________._____________________.._________._.___-______-_____.____..._________..______________________...__._ 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, an ales an regulatio "s of the San Joaquin Local Health District. (Signed) y '- (Owner and/or Contractor) ''------------------------------------- Title ------------------------------- By: ............---------- ._. ---- - -- ------(Title) {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side}. f F,011 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY XL ll-`' '��'' „------------------- DATE- 71/-4L -----------•--------- REVIEWED BY --------- --•-----------------------------'•-------------------------------- •----------- ------------------------- DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE -•------------••------....---•--------------•---------------- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------•--•--- -------------- - )------------------------ - 1x< ---------------------------------------------------------------------- ---------------------------------------•------------------------------------------ `J%t ------fr: 1` ' - � !�---------- ------------------------------------ ------------------------------------ ------------ ---- - -4 -- ----------------------------- ------------------------------------------------------------------------------------------------------- - - F FINAL INSPECTION' BY:--------- `_____________ Date i � SAN JOAQUIN LOCAL HEALTH DISTRICT 134 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 - Reviseci 1-57 FYCO.