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x{,211 APPLICATION FOR SANITATION PERMIT Permit No. __1._ _x:3_ (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 compliancewith oount y Ordinan ;II.NAft 549.©,l JOB ADDRESS A LOCATIs4••i"------------------------------------�►-.i�,,..,� Owner's Name -------- _ ---------- .... - --• --------"Phone.t �joneAddress - �Q 4- - ----- ---- - - ---- Contractor's Name----- - - --- ----------------------•-------------------------------------------------------------------------------------------------------•---------- Installation will serve: Res' ante A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: ___ I___ Number of bedrooms . ----X--/PO ------_------------------ j `�.. Number of baths ___ ___ Lot size __.. 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 ❑ ClayX Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes x No ❑ FHA/VA: Yes ❑ Nox TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if public e_sewris available within 200 feet.)Septic Tank: Distance from nearest well___ -8ance fro foun�tion-_--1.0_ _-____-My�teyial_- _______________________ ______________-.l�No. of com artments___ ___-_________--_.. J j1_______Ca Capacity.-.? �`p p ,X e'�.:� Liquid depth P tY Disposal Field: Distance from nea t well._�,�3____ Distance from foundation__�_IO........... Distance to nearest lot lite__._._...__. NKNumber of lines______ _----------------Length of each line„'�#_M-fl- ��I of trench___�.4_____________________ _` Type of filter material__�� `___• ,, Depth of filter material___ LY ------------- Total length ----- kf'¢_�O___________._____:_--__. Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------------------- Distance to nearest lot line ----------------- 171 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 -------------------- ._-_-_________-_____.. C ❑ Distance to nearest lot line ------------------------------------------------------------------------- Remodeling and/or repairing (describe): -------------------------------------------------- -•---•------------- -------------------------------------------------------------------------------------•-------------•----------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------=--------------------------------------•-----------------------------------------------=------- ----------•----------------------------------------------- ------------------------------•---------------------------------------------------------------------------•---------------------------------------------------•--------------------- ----------------------------------------- I her certify that I have prepared this application an,,d that the work will be done in accordance with San Joaquin County ordinance S to laws, and rules an r lations ofie $ Joaquin Local Health District. b (Signed) ------- -- --- ---- ---- ---- ----------- -- -------------------------------------------------------- (Owner and/or Contractor) BY'--------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, shoving 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 -------------------------------------- ------------------------------------- DATE -------I''-' ------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------•---------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------- ----------------------------------------------•----------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------•--------•---------------------------------------------------- ----------------- --------------------------------------------------------------------V--------------------------------------------•-------------------------------------- -•---------------------------------------------------------------- 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.