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APPLICATION FOR SANITATION PERMIT Permit `I i., ...... QA {Complete in Duplicate} / 7 Date Issued -��19f-:�.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. JOB ADDRESS ANDIOCATiON---.__------7 ___,-__ •_/ �,lh Owner's Name ' —-- ------ Phone------------ -------------------- Address------------------- x ------------------------- --- Contractor's Name----------- Phone--- - - ----'�k -- ------- --------- ---- --- -- -------- --- Installation will serve: Residence Apartment (•~louse ❑ Commercial E] Trailer Court E] Motel ❑ Other ❑ . Number of living units: -- Number of bedrooms j--- Number of baths -_ , Lot size ------1100--K-1 11-10, --------------- Water Supply: Public system J;U Community system ❑ Private X'. Depth to Water Table .'fid_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [3( New Construction: Yes K No D FHA/VA: Yes ❑ NoK TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from- nearest wall-----------------Distance from foundation--------------------Material ❑ No. of compartments--------------------------Size---------------=----------------Liquid depth--------------------------Capacity--------- ------------- Disposal Field: Distance from nearest well-----------------.Distance from foundation_- -_--_-_-.____--_Distance to nearest lot line_--- __------- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench.------------------ ------_ -- -__ Type of filter material-----------------__.----Depth of filter material------__-__--.--------Total length------------- ------------------- ---------------- Seepage Pit: Distance to nearest well-Al-0--------Distance from foundation__J_Q._ _.___-_.Distance to nearest lot line,-4.r_f._-_ Ek Number of pits-- -----�------- ---Lining material___-_�_-._Size: biameter_.92------------.Depth__-.,2 `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):------------------------------------- ----------••---------------------------------- -----------------•----------- X -------------•-----------------------------••----------•------------------------------------------------------------------------------------•---------------------------------------•-------------------- 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, and rules and regulations of the San Joaquin Local .Health District. 4(Signed). - -----•--- - -� (Owner and/or Contract VOor} By:------------ - - ---- - --------- Title ------- --- -----[ ) --------------------•---- (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---- ---- - BUILDINGPERMIT ISSUED------------------- ----- ---------------------------------------------------------- DATE--- - - ----------- -- ---------------------------- ------------------------- - Alterations and/or recommendations: g J�: -- --------- ( --- _3---------f - ---- - ------------------------`}--------------------------•---------------------------- -- --------------------------- FINAL INSPECTION BY-------- - -------. ----------------- Z — _ S Date ------------------------------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M , Revised 1.57 F.P.CO.