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C �: C�� APPLICATION FOR SANITATION PERMITro , (Complete in Duplicate) 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. fi ------r c_ �� 1 e= ------ --------------------- ,JOB ADDRESS AND LOCATION-----------------`---=---------------•-----; -- - -- - -----------------------�---------.--------:----------�. r. „ / Owners Name------------------------------------------- `mss';r.- ,E7`=: Phone r"� .'Y , :r Address----------------------------------------------------------------'" ---------------�---_--�-===------=--------------------------..-..------------------ ------------------------------- ------------ Contrac.torl Name---------------------------------------------k =E' =' /--------------------------- ---------------------------- Phone_.----------------------- Installation will serve: Residence (0---Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --j-.-- Number of bedrooms __-/___ Number of baths _ ---- Lot size ---- r _1___,...2-------------------___-____- 1 Water Supply: Public system ❑ Community system ❑ Private ❑-rf]epth 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 ❑ No E3 New Construction: Yes E]- * o ❑ FHA/VA: Yes ❑ No 0' 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-.�- ---------Liquid depth--_-�2-------_---____--Capacity.__-x'-_1'?-.---__- Disposal Field: Distance from nearest well_ ________-Distance from foundation-__e`0-_-----_----Distance to nearest lot line----'_------,_-._- , Number of lines- -1_ * Length of each line------- _--_ Width of trench-.-_*."; _` Type of filter mat erial-_---� t,rL--------Depth of filter material-----I _--------_-Total length--------- --------------------------- Seepage Pit: Distance to nearest welt--------------- l Distance from foundation-----------------_Distance to nearest lot line------------_-.-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---.-------------------Dept h------------------------_______-- Cesspool: Distance from nearest well-----------------Distance from foundation--------------.-----Lining material------------------------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well------------------------------------------------- from nearest building------------_--_---------------------------------------------- Y G, ❑ 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 laws, and rules/and regulations of the San Joaquin Local Health District. (Sign ed; .-_-----�-_ -------------------------------------Owner and/or Contractor �.f By:-------------------r--------------------------------------------------------------------.-..__.-------------------------------(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------ s ----------------------------------------------------------------- DATE------ ;7 57V----------------------- REVIEWED BY------------------------------------------------------------------- -----------------•---------------------------------------- DATE----- ------------- - --------------------------------------- BUILDINGPERMIT ISSUED------------------------ ----------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or r mmend 10 :--- - _ --- -- -------------- ---- ------------------- - --- -- -•_--__-_- - - -- -- -___-- - - ---- - ----------�-__ - ._- _•- •-•_ __-_�---� �(---------------------------- ----- - - -- -_--_-__ __ ---. /n- ------------------------------ ---- ------ ---- ------------ ------------ -------------------------------------------------------------------------------------------- ------------------------------------- FINAL_ INSPECTION BY---------------- ---- Date------------ ---------------- 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. 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