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APPLICATION FOR SANITATION PERMIT Permit No. ___!-_ __G--`-:�-Z {Complefe in Duplicate) (1 10 Date IssuedS_ --- 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. 5}49. JOB ADDRESS AND LOCATION___. j-- � uV� ------------------------------------------------------------------------------------- Owner's Name----- -'M------------------ -------------------------------------------- Phone----------•------------•--------- Address-----•----'--c?"-- ------- ...1Q-��--------------- Contractor`s Name �'� '� F ---------------------- Phone __. sSz7 Installation will serve: Residence Apartment House ❑ Commercial �8 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths I_____ Lot size _-_----__-_-_------ Water Supply: Public system Vj Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand [❑ Gravel Ej Sandy Loam ❑ Clay Loam ❑ Clay ELL] Adobe,] Hardpan ❑ Previous Application Made: Yes ❑ No 2L 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 Tank: Distance from nearest well,-?v-^Z_____-Distance from foundation_jp__Ir_______.__Material_-----_: 91 No. of compartments------ -- ---------------Size-- --x- -- -9.------ C� �j __ Liquid depth------�-r �----------Capacity---��- "�-- tSU Disposal Field: Distance from nearest well�'�[------Distance from foundation_'-_�_.._______.Distance to nearest lot line-S___________ b] Number of lines-_-------I------------------------Length of each line____-0- ---------------Width of french----�2-4---------------------- Type of filter material------�-4.Ck_______Depth of filter material__-._1 _ .......... length------- ____________________________ Seepage Pit: Distance to nearest well-�t----------Distance from foundation___!i� _�______-Distance to nearest lot line____°5__r_..._ IN -_`cC Number of pits__..---t_____________Lining material -------..Size: Diameter----; " ----------- --Depth-------a's-�--------------- , Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____--_________ y ---------------------- Size: Diameter--------------------------------------Depth--------------------- ----------- -----------------Liquid Capacity--- ------------------------gals. Privy: Distance from nearest well--------------------------------- _____.___-_---Distance from nearest building----------------------------------------- El Distance to nearest lot line------ ----------------------------- ---------- -------------------- � Remodelingand/or repairing (describe):-------- ------------------------------------------------------------------------------------------------------------------------------------------------ - . ------------------------------------•------------------------------------------------------------------------------•--------------------- ------------------------------------- -------------------------------------------------------------------------------------------------- o ---------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re ulations of the San Joaquin Local Health District. (Signed)----------- --�'-`---- ----------- -----------------------------------------------------------------------------------------------Owner and/or Contractor) By:--------------------------------------------------------------------------------------------------------- ------ -------------------(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 APPLICATION ACCEPTED BY_____---E -�- ---- -_ «- ---` - ---------------------------- --------•------------ --------- DATE_-------�L-----�-�-�- --------- IEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE - ----------------------------------- UILDING PERMIT ISSUED------------------------------------------------------------------------------------ ---------------- DATE------------------- ---- Alterations and/or recommendations__________ _-----____._.. , _-•------- ------------------------------------ ----------------------------------------------------------------------------------- --------•--------------------------------------------- -------------------------------------------------------------------------- ------------------•------------------------ ----------------------------- ------- FINAL INSPECTION BY: -�...(A-6--, _c'W!etr ----- Date----.- ..`_�-7._�- _p--- - 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 Reviseci 1-57 F.P.CO.