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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued __--- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor, herein described. This application is made..in compliance with County Ordinance No. 549. "(' l�0 5- ,1 ,414 c�a-� .•P_-o 1 . JOB ADDRESS AND/J LOC TION_ il -- Ti!/ _'-�- of ` Owner's Name---�.0 .y� --- ---- &� - Phone ------------------------------------------------------ Address----------------� -1----------------------------- "-"-------------------------------------------------•----------------------- Contractor's Name_ ------ ---------------- -------U--•--------------------- �2A --- ------------------------ Phone---------------------------------- Installation will serve: Residence ❑ Apartment House [:]' Commerci I Trailer Court ❑ Motel ❑ Other ❑ Number of h •n 7units- ------l__ Number of bedrooms -------- Number of baths _*--_ Lot size ---�_�- --x_ _a0--------------- -- Water Supply: Pub�ic� E" Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ ; Gravel ❑ Sandy Loam [+Clay Loam [] Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes Q No 'New Construction: Yes [ir"'No ❑ FMA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspooh permitted if 'ublic sewer is available within 200 feet.) r •i • Y - E SepticTank: Distance from iZarest well"'( Dista ria f.pin f ynldation-`r _ Mater L-- - - -------------- --- ------- 0 of compartments"'-.ti""", � `Size-�- -yC- ------- Liquid eP.�h ----------Capacity -------------- No. . Dispos I Field: Distance,�f om nearest weA1 _�Distance from foundation /0 Distance to nearest lot • _ o r ^-'Number. of; lines_-_.- --- -f,___ ------_ Length of each line------------------- Width of trench-_-------Z, r Type of-filter materi `'C 1_Depth of filter material--_--19----------Total length-------- l' ------------- --- Seepage Pit: Distance to nearest!well_---�-----------------Distance from foundation--------------------Distance to nearest lot line__-_------------- ❑ Number 'of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- (J' Cesspool: Distance from nearest well-------------__-Distance from foundation-_--_______:------_Lining material_-------------------------------____-. F1 `Size biarneter----- -------------------------------Depth----------------------------------------------------Liquid Capacity------------------ gals. Privy: Distance#from}nearest well-------------------------------------------------Distance from nearest building--------------------------------------- ❑ Distance to nearest lot Iine--------------------------------------------------------------------------------------------------------------------------------- ! ,dnd/or repairing: (describe) ^' -n-� !� 4 f� -------- Remodeling �..� s - -------------------- ��/-�_x...-=-----_�2.-------------------- �:x~—,RC2..-..--�,�' - -- --- -- - --- -----•-- - --- -- •- -----fO — l ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County uI tions of the San Joaquin Local Health District, ordinances, State laws, and rules and rpgl r Signed. ----------------------------------------------------------------------------(Owner and/or Contractor) B ----------------------- - ------- --------------------------------------------------------------(Title)----------------------------------------------------------------- y:(Plot plan, showing ize of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-?-- ------------------------------ ---------------------• ----------------------- DATE-V---------------------------------------------------- i REVIEWED BY------------------------------- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------_2k----------------------------------------------- Alterationsand/or recommendations----------------------- ----- ---- -----------------------------------------------------------•-------------------------------------------------------•------- L '- -- ----------------------------------------------------------•---------------------- -----------------------------------•----------------------------------- ---- -----------•------ --•---•--------- -----------•----------- -- ------------ ------------ -------------------------- ---------------------------------- -------------- ��(P )) FINAL INSPECTION BY:------ -- Date 1-----.. + 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.