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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued -_- f 3�5 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 LOCATIION-1/ __, Cl/"G__ ,,S3gf , 'Ply �- !__ ` Gig_, xf9A ____ i _ • ---_-- Owner's Name------- , ..... ------ Phone.................................... Addres r,�•r '1-.�-`�,-;/,0 ........ , }/l ---- --- --- Contractor's Name............... -------------------------------- ---- •------ Phone----------------------------------- Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1.__ Number of bedrooms ._ _. Number of baths _f_... Lot size ___ ._ � Water Supply: Public system 01"Commun'ity system gg"Private ❑ Depth to Water Table"/.2 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes No PP New❑ ❑ Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Distance from nearest well------ Distance fr m foundation.../.P.----------Material..k-4_ No. of compartments_-_ .__._.__._. Size_ 4�..___ _ _ -Liquid de th-_-__-Y- ..........Capacity _ Disposal Field: Distance from nearest well---- Distance from foundation.....id-- "--,Width _. Distance to nearest lot line-07...__ [ Number of lines--------- ,__ en th of e ch line.-S. 9 �s�-- of trench—.df, ---------------- Type of filter material.. epth of fil er material----- ?s•------Total length-----/le ------ 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 fr m foundation____--______---__.Lining material_-_-__--_-_-____-.-_-__.------------ ❑ Size: Diameter-------------------------------------Depth------ - --------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___-________________________________ ______-Distance from nearest building__-______--_.-_________---_-_____--__-._. ❑ Distance to nearest lot line Remodeling and/or repairing (describe) ---------------- ------------- ----- ----•-- --`- f ----------- y.- --------•-------•--------------------------------------------------------------------------------------- -------------------------------------------------------------------••-------------------------------- I hereby certify that I have prepared this application and that fie work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r ulations of the San Joaquir Local Health District. (Signed)- - / ( _ FCo tractor) By:-------------------------------------------------------- (rifle),- )---- - --�'----------------- - ----------- (Plot plan, showing size of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). Wj FOR DEPARTMENT USE ONLY d APPLICATION ACCEPTED BY------------------------------- ----------------- DATE. EVIEWEDBY. -------------------------------------------------------------- ------------------------------ DATE........;.t'-- ------------------- 5 BUILDING PERMIT ISSUED ---- -------------- - --------------------------------- DATE. Alterations and/or recommendations: -------------------------------- ---------------------------------------------------------------------................................ •--------------------•------------------------------------ -------------------------------- - ----------------------------- `. -------------------------•------------------------------------------------ - ----------- FINAL INSPECTION BY--------------- Date------- I?- ' 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 , Revisea 1.57 EP-CO.