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r i APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) i This s Permit Expires � Year From Date Issued 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. I G JOB ADDRESS /AND LOCATI N_..__ q--- Owner's Name---l�-- ---------- Phone--------------------•---------•---- Address - ------------ ------------------ - -- - Contractor's Name.--- - --- • --------.&_ _��, C-I / -- ------- Phone--- u_. .�_0. ... Installation will serve: Residence ❑ Apartment House ❑ CommercialTrailer Court [] Motel ❑ Other Number of living units: �______ Number of bedrooms ____I___ Number of baths -- _-- Lot size __.0-V _ _ __ _ _ __________ ______ � [___ .Water Supply: Public system ❑ Community system ❑ Private$) Depth to Water Table "S-____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No Pq New Construction: Yes ❑ No A FHA/VA: Yes ❑ 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-----------------Distance from foundation__________-___-__-_.Material---------------_--------------------------------- ❑ No. of compartments-- -----------------------Size--------------------------- ---Liquid depth----------------- --------Capacity---------------------- % � Dis�al Field: Distance from nearest well-_-_,S4-- _--.Distance from foundation____��??` _-----Distance to nearest log line_________________ Number of lines.-...............___. ._______ ---Length of each line---------i __ Wid#h of trench___ __f__ ----------- Disposal _ ________ Type of filter material________„h. .li___Depth of filer material----:�- Total length----------- __ �'_-------------- Seepage _-_____. __Seepage Pit: Distance to nearest well____------------------Distance from'foundation__________ ---------Distance to nearest lot line-_-----.______.__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- I Cesspool- Distance from nearest well____.___________Distance from foundation-------------------_Lining material-------------------------------------- 171 ._._--_._____________.___________.__. ❑- Size: Diameter--------------------------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------_....Distance from nearest building-.______-_._______________..__..._-._. ❑ Distance to nearest lot line------------------------- ----------------------------------------------------------------------------------f�-------------------- - Rem deling and/or repairing deVscribpe):------ o`/" rT+• 14-- - - - �G- " ' - - ----- ---- ----416 — -- ------ ----- -- ---------------------------------------------------------------------•--------------------------•I----^'--- --------- ---- 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. (Signed) __________________(Owner and/or Contractor) By:------------------------- ---- --- Title - --- ------------------------- (Plot -------- -----------.._(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:------------------------ -----------------------------------------•--------------------------•---••---------------------------------- a --------------------------------- ---- ------------- ----------- -------------- ---- ------------------•-------------- --•--------------------•--••---•----------- -------•-------•------------------------------- I i ---------- } FINAL INSPECTION -- � 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-92M Revised 8.'59 F.P.eo.