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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) r't" sf Sy } Date Issued ____________________ i M Application is hereby made to the San Joaquin Local Health District for a permit to construct and insta!Pe work he ei ascribed. This application is made in compliance with County Ordinance No. 544. JOB ADDRESS AND L CAT ION---- rk7 +t ----sa- -------- Phone---- --.--- ----------- -------- � ------- - - Owner's Name--------------- - -- +1 �"' �' '! ----------------- Address----------------------------- Contractor's Name---------- --- --• Phone. 1 Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ Number of living units: ._-:_ Number of bedrooms -3--- Number of baths I---- Lot size �17_�------------------------- l Water Supply: Public system ❑ Community system ❑ Private .` Depth to Water Table -------- ft. 1 ' Adobe Hardpan Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑,"Sandy Loam ❑ Clay Loam ❑ Clay ❑ ❑ ❑ Previous Application Made: Yes [I No jEr�_New Construction: Yes to ❑ FHA/VA: Yes E] No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 2Q0 feet.} _ v t r 1, f�-']2'!�Material---- �-P9:;� ------------- Septic Tank: Distance from nearest well_EO C?^_ Distances from foundation_ - Capacity �_d----• , No. of compartments----- ----------------Size--T"�E-- X `� ------Liquid depth--- ----------__- -- P Yr Disposal Field: Distance from nearest well5—OY'"___Distance from foundation--1 _'�^ `D;stance to nearest lot lye--_---. 1571 Number of lines----------A- ------ ---Length of each line - ----------------Width of trench--- _}�j JG't .. ,�} q = Type of filter material.__-S-, e(`_Depth of filter material-----�_ ___---__--.Total length -- F1 Seepage Pit: Distance'to nearest well----------------------Distance 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-------__-__------------------------ ❑ -----Depth---------------- -----------Liquid Capacity gals. Size: Diameter---------- --- ----- ------- -------- --------- Privy: ¢Distance fromnearest well----1-------------------------------------------Distance from nearest building----.__--..-.---------------------------- Distance to nearest lot line------------------ Remodeling and/or{repairing (describe):---------------------------------------------- __ --.--_Z ! # i -----------------•-- -- ------------- ---------- --------------------------------------•-------- ------------------------- ________ 1 ------------------------------- ..-. •---------------------- -------------------- ty I'here6y certify that I have prepared this application and that the work will be done in accordance with San Joaquin oun i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_ (Owner and/or Contractor) - - - ----- --------------------- Title ---- --------------------- - (Title) - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side)., r . � r FOR DEPAMENT USE ONLY 07APPLICATION ACCEPTED BY--- ` f----- ;- — `� s ATE- �� ------ DATE-------------------------------------- ----------------- BUILDING PERMIT ISSUED--------------------------------------------------------------------------------- DATE---------------------------- -- - ----------------- Alterati a d/or recommendation .-------- -------------------------- --------- -- -;------- -- �� h--- -------- �ry1.,.ear1� ------ ---- - t ------------------------------------------------------------------ ---------- ---------------------- It -------------------------------------------------- - ' FINAL INSPECTION BY---------- ;�--------------------- -- ------------------------ Date----------------------------------- ------------- --- -------------------------- [ SAN JOAQUIN LOCAL HEALTH DISTRICT 132 S camore Street 814 North "C" Street 130 South American Street 300 West Oak Street y Trac California Stockton, California Lodi, California Manteca, California Y. ES-9-2M4 Revised i-57 F.P CO.