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APPLICATION FOR SANITATION PERMIT Permit No. __Z��.-�__ 1 S (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 �wyith/C�ounty Ordinance No. 549. JOB ADDRESS AND LOCATION...(/ l ---------- --- -----•--®'----------------------------------------------- `` Owner's Name--- :--•--•---�/,�_/(%�_S_1¢1�-_------ --------------------- ---------- --------------------- Phone------------------------------------ �_��-G-�-��- Address--------_-�i r�-"ME----------"----------------•-----------------------------------------------------•----------------------------------------------•--------------------------------------- Contractor's Name ------------ r%_1.,---------------T------------------------------------------------ ------- Phone ----------------------------------- Installation will serve: Residence ©'Apartment House ❑ Commercial p Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --%-__ Number of bedrooms ___f _ Number of baths --4__ Lot -size o __ .P,h__ _GP ___________________________ Water Supply: Public system ❑ 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 gil"Hardpan ❑ \ Previous Application Made: Yes ❑ No, RT"`�New Construction"; ❑ No I�FHA/VA: Yes ❑ No ®-' (� TYPE OF INSTALLATION AND SPECIFICATIONS:" (No septic tank or•cesspool permitted if public sewer is available within 200 Septic Tank: Distance from nearest well_`_t�_�_____D'I;tance_ romaterial_____------------ No. of compartments_--__A_j_------------- Liquid depth_4_ _-------------Capacity___�_IQ�------ 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 -------------------------- bepth„of filter°-materialti----____-____:____-_Total length ________________----__-_----__-___________ Seepage Pit: Distance to nearest well -_------------------ from foundation___________________ Distance to nearest lot line --------------- [] Number of pits ---------------------- Lining material ----------------------- Size: Diameter- ----- ----- --------- Depth ___-_____-_-___-__________------- Cesspool: Distance from nearest well ----------- -- -+_Distance from foundation '.Lining material -------------------------------------- ElSize: Diameter---- --------------------------------- Depth -- ,----------------------------------------- ` Liquid Capacity gals. Privy: Distance from.nearest well ------- _----------------- _----------------------- Distance from nearest building ---------- -___________________-___-____._. Distanceto nearest lot line----------------------------------------------------------------------------------------------- --------------------------------------------- Remodeling and/or repairing (describe)_____________/VV_ y ___ -- ------------------ - t - -------------------- - rllrw~F-------=---------=------____----------------I-----------------------::::_:_:--------------------------------------------.------------------------------------------------ -- ------------- ---------------------------------------------------- -t ----------------------------------------------------- ------------------------------------------------ ------------- ---------- - -- 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',Disfrict. , J ; /i. ------- : 1 (�r Contractor) . t� F (Signed) -------••--------- -� 'R�-------- &;q -- --------- ----- --- - --------------------- ------ } :--(Title) ---- : -------------------------- (Plot plan, showing size of lot, locat' of system in relation to wells,—buildings,--etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED,BY__________________-_______-____. REVIEWEDBY ------------------------------------------------ ------------ BUILDING PERMIT ISSUED_ ------------------------------------ Alterations and/or recommendations_______________--- ----- ---------------------- DATE-------------------------- ----------- --------------------- DATE------ --------------- �------------- ------------------- DATE----- -- --------------------------------------- ---------------------------------------------------------------------------;_ - ------------------------------------------------------------------------------------ 7— / � I FINAL INSPECTION BY:.- Date /----------------------- ------------------- SAN JOAQUIN LOC -{ HEALTH DISTRICT � } � } '� 130 Soufh American Street 300 West Oak Street `132 Sycamore Sfreefi 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised 1-57 F.P.CO_