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V APPLICATION FOR SANITATION PERMIT Permit No. ....�f. 7�r7.... (Complete in Duplicate) •r/l 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. 549. JOB ADDRESS AND LOCATION T, -- -------------- �`'� -------- - -_------- Owner's Name-,/-- Address ame:f/ ------------------------------------------------------------ - ----- - - ----•--------------------------Phone....--•----•------,_..--�-•--------- Address $7� ..........--•- --------- •---•• • . ----------------------- ....................................................... Name..... .... .. _--�.r�_ Phone.. d `.� 7 Installation will serve: Residence S Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: j_-_ Number of bedrooms ._Zl Plumber of baths __/. Lot size .......,t.,C ,,,.�- ,.............................. Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _'1rd ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan❑ Previous Application Made: Yes ❑ No 2:__-New Construction: Yes ,®„__No ❑ FHA/VA: Yes K— 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--Ze-Q-1-----Distance from foundation-2-0-1,_..._..Mater' I GG No. of compartments___ _____________Size_ _ _._..Liquid depth___ ____Capacity Disposal Field: Distance from nearest Distance from foundation.__412�9__ Distance to nearest lot line.... _f Number of lines........... _ ______Length of each line---------Z. .......Width of trench........ !........ Type of filter material_f _,__ Depth of filter material-------- length--------- .............. Seepage Pit: Distance to nearest ----------Distance fr m foundation-_-- -.Distance to nearest lot line__ ------ 9 Number of pits__-_/____-______Lining material... G .Size: Diameter__--a~-........Depth----- �j_....._.. 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---------------------------- ---•-------•-------------------------------------------•-------------•-----•--•-•-------•-----••---------------- Remodeling and/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, State and rules and regulations of the San Joaquin Local Health District. ��. (Signed)---- -- -`-�-- ----------------------------------------------------------------(Own r and/or Contractor) BY� - -----------(riifle)------. (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 APPLICATION ACCEPTED BY - ;---------------------------------------------------- DATE......�.--------------------------------------------- REVIEWEDBY-------- - ------ --- - -------------------- DATE---- ------- ....................................... BUILDING PERMIT ISSUED DATE ----- ------�• -------------------------------------------------------- Alterations and/or recommendations: - -�---------------------------------------------------------------------------- ...... ".----..---- _: -t-"T ------ ---- .�----®- --------------------------- ---•-- ------------------------------------------------------------------------------- ----•----------------------------------------------------------------------------------------------------------------------- ------------------••••-••---••--•---------------•--••---•---------._..._....•----....----•-. FI ------ Date---' — ----------------- NAL INSPECTION BY------ --------- �--------- � -------- 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.CO.