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APPLICATION FOR SANITATION PERMIT Permit No. _116.5 ----_. (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 herei described. This application is made in compliance with County Ordinance No. 549. ADDRESS AND LOCATIO N------ -----/------------------ -------••}--------------- E--------- JOB------•---- Owner's Name ----------- -------------..��'7(_Phone. +; ----- '`�= -------------_------ Contractor's Name_--------•---------•----------------- -- -- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: Z____ Number of bedrooms ,3____ Number of baths I____ Lot size --- ,7Q_x---- Z- ------------------------ - Water Supply: Public system ❑ Community system ❑ Private R"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 ❑ No ❑ New Construction: Yes ❑T No ❑ FHA/VA: Yes ❑ No ❑ T TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) K r . --------- Septic Tank: Distance from nearest weiL_rI_'bistance fro fou dation_�i�-'r'%cw�.Ma erial____�a!?-_- p Ix No. of compartments -------��---------------Size.&---x-�x-�-----Liquid depth, -------�........ .------Capacity---�oa------ 61 r Disposal Field: Distance from nearest well__$R�'.`_`D+stance from foundation_/d_._______--.Distance to nearest lot h�e__s-- Number of lines---_--_- -- -_�_ _- - -- .-- Length of each line- -lam--------------------- Width of trench.-- ----------------------.--- �/ 1 �--Depth of filter material ---- length -------2 Oa Type of filter material-____rrG, Seepage Pit: Distance to nearest well ---------------------- Distance from foundation ------- _............ Distance to nearest lot line --------_------ Number ___----._--____Number of pits---------------------- Lining material----------------- ----.Size: Diameter---------------------- Depth------ ------------------- - Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material_____________________________________ ❑ Size: Diameter------------------------------ ------- Depth ---------------------------------------------------. Liquid Capacity ----------------------------gals. Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ---------------------------------------- F-1 Distance to nearest lot line ------------------------------ -------------------------------------------------------------- ------ Remodeling and/or repairing (describe) --------------------------------------- ----------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- ----- -- --------------------/-------------------------------------------------------------- -....-------------------------------- J2------------------------------------------------------------------------------------------------------- --------------------- ---------------(ve------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I hrepared +his application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and_and regulations of the San Joaquin Local Health District. (Signed)_--------•--,--------------------------------------------------- ---------------------------------------------------------------------------------------------(Owner and/or Contractor) By:--------------- ---------- ----- - -- --- Tale - -- - - - ----------------------- - - - [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------- --- --- A ----------- DATE -----��f/-1�--d------ REVIEWEDBY ------------------------------------------------------------------------------------------------------------------------------ DATE --------------------------------------------------- -------- BUILDINGPERMIT ISSUED -------------------------------------------------------------- -------------------------------------- DATE ------------------------------------------------------------- Alterations and/or recommendations----------- -------- -------------------- --------------------------------------------------------------------------•----------------------------•-- ------------------------------------------------------------------------------------------------------------- ------------------------ V ----- ------------------------ - - -------------------•-------------- .----------------------------------------------------------- -------------------------------- ----- INSPECTION BY------- ------------- -- ---- - ------------- Date-------�-- ---�----•--- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street_ _ -__132_ Sycamore Street— _ T-814'-N&O " C..Screat _ �---Stoekton, California Lodi, California Manteca, California Tracy, California ES -9-2M , Revisea 1.57 P.P.CO.