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� f APPLICATION FOR SANITATION PERMIT Permit No. .-1.._3z--- --� (Complete in Duplicate) J/ 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 C S'_(-77' S � ZC! -pZ.e� -11 JOB ADDRESS D LO 05 ____ -= � - ----------- ------ ---- Owner s Name--- Phone --- --- - - -- - -- ----------------- - Address_.. ' ` + Contractors Name-------------- ----- ---------- Phone----------------------------------- Installation will serve: Residence Apartment House. Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms,-Q__ Number of baths ---!___ Lot size M----- Water Supply: Public system ❑ Community system ❑ Private ❑ Dep to Water Table ft. 4 � Clay Character of sail to a depth of 3 feet: Sand 0Gravel ❑ Sandy Loam ElClay Loam ❑ ClY ❑ Adobe C] Hardpan Previous Application Made: Yes ❑ No A' New Construction: Yes A 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 Tank: Distance from nearest well__+�._____-_Distant fro found ion___ /__ _ M.af rill______ ____ __ _ ____ _________ ________ �yy�� f ----- - No. of compartments______._f' ____Size_, _ -, -"-Liquid depth_____1�---- Capacity__._-@ Disposal Field: Distance from nearest well ___'-'---------_.Distance from foundation____1__g_____.Distance to nearest lot line Zt_ ------ - Number of lines--------I--------------- ------ Length of each line----��--- Width of trench.-_. °��------------------ Type of filter material__5��(gepth of filter material_-------/ _ __ _Total length-----------,S710------------------- -4 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___._______-_____-----_-_____________. ❑ Size- Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------- gais. Privy: T Distance from nearest well.------------------------------------------------Distance from nearest building----------------------------------------- ElDistance to nearest lot line------------------------------ -- -------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------ ----------- -------------------------------------------------------- ---- --------------------------•----------•-----------------------•----------•---------------------------------------•-------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) - ------------ ------ (Owner and/or Contractor} Title (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 APPLICATIONACCEPTED BY--------------------------------- --- --------------------- -------------------------------- DATE_----------------------- --- ----------------------------- REVIEWEDBY---------------------------------------------- ----------. DATE-------- --- BUILDING PERMIT ISSUED------------------------------------------------ ---- DATE---------- --- ---6--� ----- Alterations and/or recommendations------------------------ -------------------------------------------------------------------------------------•--------- 4FINAL INSPECTION BY:.-------- ------ -------------- Date----------------- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT f 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.