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� T5 �b 4 6 a APPLICATION FOR SANITATION PERMIT -. a " Permit No. -- - •- � � APPL C `� _ (Complete in Duplicate) Date Issued P plication 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 LOCATI = r =?I +` ------------------------------------------------------.------------ AO.v Owner`s Name = 1 4 Phone_ l� L# ------------------- Address------------------------------- l I 1 ------ - ------------------------- ------------------------------------------------ I _ l one-------------- •--------••--------- Contractor's Name--------------- - --------------------------------------- ------------- Ph Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1____ Number of bedrooms i.----)Num er of baths __�`___ Lot size _____ --}�-1- L ------_.______ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ________ ft. P Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy-Loam El Clay Loam ❑ Clay ❑ Adobe Hardpan [I Previous Application Made: Yes ❑ No [ New Construction: Yes E?-<o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS:' (No septic tank or'cesspool permitted if public sewer is available within 200 feet.)"", eet.) f Septic T nk: Distance from. nearest well __Distance:f ram foundgtion____10-_______.Material______ ___ _ ____ ____ No. of compartments_./ - ---- Size_ -� ':` Liquid depth------�-�j---------Capacity 0''`'- Disposal Field: Distance from nearest welly.--OLP-__.Distance.from foundefion.jO______..___.Distance to nearest lot line._O____-______ ' Number of lines---- ------------Length of each line---- rt-� ------ Width of trench__ ',-- --------- Type of filter mat erial___�IJ-L--------------Depth of filter material-----f ....Total length_________-,/3�-----_------------ �._.. � i / See a e Pit: Distance to nearest well- - DiCial from unda#ian__-_/_4____ ____.Distance to nearest lot line_., > 1 i 1 ----------- Number of its _ gSize: Diameter_____��__ De th___._ ._ p �- --Linin mat - - pCesspool: Distance from nearest well________________Dirom foundation_______.__._-,----.Lining material___-------__________._____.________ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals F1 Privy: Distance from nearest well --------------------------------------------Distance from nearest buiicling________________------------------------- 1 ❑ Distance to nearest lot line-------------------- -- ----------------------------------------------------------------------- - - ------------------------ 4 Remodeling and/or repairing�{describe):_ =------•---------------- ---------------------------------- -------------------------------------------------------------------------•-------• I , .. ------ , ------------------------------- --------- ----------------=--------------------------------------=---------------------•-•------------------------------•----------------------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County or inances, State laws, and rules and regulations-of-the-Sen Joaquin Local Health District: Contractor] (Signed)_ • - [Owner and/or or - - Tale ` ----------------------------------------------------------- --- (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 ----------------------------I APPLICATION ACCEPTED BY---- ----------------- ---------------=--------------- DATE------ --------- REVIEWEDBY----------------------------------------------------------------- --------------------------------= ;'------------------ DATE-------;--------------------------------------------------- BUILDING PERMIT ISSUED---------) -------- ------------------- ;-------------� -` '= j DATE -- Alterations and/or recommendations: ------------- --------- - ---------------------- ---•----=---- - -- ---- - _ _ 7��A --- ----- � ------------- ------ ----------------- -------------------- --------- FINAL INSPECTION 8Y:____v. ._--� -- Date-- ------------• --------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street F 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M , Revised 1-57 F.P.00.