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APPLICATION FOR SANITATION PERMIT Permit No. vi (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. JOB ADDRESS AND LOCATION ------------------•-------- Owner's Name---- J---- •-- ' � -------- Address------------. ..`� - - ---- Contractor's Name - ca:(_44 -+.. ---------------------------------_------------------•----•---------- ------•�he -----•-----•-----••-------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ , tel ❑ Other ❑ ee Number of living units: ---I--- Number of bedrooms _t_- Number of baths .__I___ Lot size _-_--�'� G?..�'`___________________-_ Water Supply: Public system ❑ Community system Y Private ❑ Depth to Water Table/,!:;,-_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p Clay k Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No 9 New Construction: Yes K No ❑ FHA/VA: Yes ❑ No [ " TYPE OF INSTALLATION AND SPECIFICATIONS: _"? (No septic tank or'cesspool permitted if public,sewer it available within 200 feet.) Septic Tank: Distance from nearest istance fr m foundation__._ _ -1 ---.Mete/ial----Ct�l� ------------ No. of compartments____--_ Siz __ x__ :___Liquid depth__./_____1 -____Capacity..�'�_�___-__- Dis al Field: Distance from nearest `w istance from foundation. /-5 to nearest to line__ ___________ Number of lines-----, ______ r___ _______LAth of each line__•'�-�'____.�:_..._.Width of trench ___' _ fl _____________ Type of filter material-__]/_ Depth of filter material__/_ `11_________Total length-___ ____________________________ Seepage Pit: Distance to nearest well---------------------- from foundation....................Distance to nearest lot line----------------- ElNumber 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------------------------------------------ Lv ❑ Distance to nearest lot line ` - • �Q Remodeling and/or repairing (describe):-----•_- - :_---� ,� ---•- ------------------------ :---_ �• --•- -•-------------------------------------;-----------•----------•-------------------F-------------------------------------------------------------------------------------------------- ----- -----------•-•--------- --------------------------------•------------------------------------•-------------------------------------------------------------------------------------------------------------------•------------------------------------ ----------------------------------------- -------------- ---•--------------------------------------------------------------------------------•-------------•--•-----------------------------••-•-------•------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Si nedces, State Ir�ws� les and regulations of the San Joaquin Local Health District. ( 9 ) ------ ---------------------------------------------------------------------------------(Owner and/or Contractor) -_A244� ------------------------------------------------------ - ------------------------------------ (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---------------------------------------------- - /------------------------ 1 ................. Alterations and/or recommendations: - =----------.....................--•---•-•-----•------•-•--------••-•---•--••-------•--•-•--------•--•----••----•------ ----------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------•------------..--------------------------------------------------------------------------- ------------•---- ----------------------------------- ----------------------- ------- ----- -- - Z— FINAL INSPECTION BY: R -� D � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO-