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APPLICATION FOR SANITATION PERMIT Permit No. _Z0.57-0 D (Complete in Duplicate) _ I D8te Issued Z_1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he pin describ d.� This application is made in compliance with County Ordinance No. 549. 0f2 00—Z-1 y J: JOB ADDRESS AND L CATION- i-------- -- -------- z=-�9-----5t /-_Mu _- I�.-------------------------- Owner's --`--�1. �------- --------- - ��3 -c ,----------------------------- - --(a a jA ------------------- ------------------ " - Owner's Name____________ ____ Phone__ !l ! - ---- ----- Address--------------•-•--- !��-`' .. L - _ ------- ------------------------------------------------------------------------- -------------------------------- -- Contractor's Name----------•----: t `' ----------------------------------------------- Phone----------------------------------- - ------------------------------------------------ Installation will serve: ' Residence ®-"A�partment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ Number of living units: ____ Number of bedrooms _ Number of baths __ __ Lot size _-` �_��__________________________ `► £ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ��--�t.- Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes Jo ❑ FHA/VA: Yes W-"INo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: C ci V (No septic tank or'cesspool permitted if public sewer is available within 200 feet.)f �( , � •y�— Septic Tank: Distance from nearest well---9W_ -__Qistance from foundation__ _i�_______.__.Mat rial-_- 44 :._,_ No. of compartments---------------------- Size ��----------Liquid depth------- ................Capacity---- Disposal ield: Distance from nearest well___?Q. _.._.Distance from foundation__1d------"---.Distance to nearest lot line_________________ {l� Number of lines-------/-_-------__-------------Length of each line-------- -----------width of trench----e2'_�' _�___________-_-___ Type of filter material___ya'r ----------Depth of filter materiala-----12((------Total length________ ___ ___________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------_----------------._------- Cesspool: Distance from nearest well-----------3-----Distance from foundaticr-------------------Lining material------------------------ ------- ❑ Size: Diameter_.__'------------ ------------`- -" Depth----------------------------------------------------Liquid Capacity-----------------------------gals. .,s Privy: Distance-from nearest well----_-------`_----_-------------_-----------------Distance from nearest building_--__._____________________________---_. ❑ Distance to nearest lot line._------- -----------------------"------------ Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------- -------------------------------------------------------- i --------------- --------------------------------------------------------------------=---------- ------ •-----------•-----------------------------------------------------------------------------••--------------------------------------- -------------------------------------------------- ------------------------------------------------------ - -------------------------------------------------------------------------------------------------- ------------ 1 hereby certif that'[ have prepared this application and that the work.will be done in accordance with San Joaquin County ordinanceg, t ws, and rules and re - ations 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--- --I -------------- __u,_ `-----------`------------------------ DATE------ j ` ------------ REVIEWED BY-------------------- ---------------- --------------------------------------------------------------------------------- DATE----------------------------------------------------- - BUILDING PERMIT ISSUED----------------------=--------- "--------------r' - DATE. -------------------------------------- Alterations ---------------------------------Alterations and/or recommendations------- --------------------------------------------------•---------------•-------------------------------------------------•---------------------------------- ----------------------------------------------------•--------•-----------------------------------------------------------------------=-------------------------------------•---------------------------------------------•---- -------------------------------------=------------•-- ------------------------------•------------------------------------ --- ,---------------------------------------------------•--------------------------------------- ----------------------•-------------- •----- -------------------------------_----------------------------------------------•-------------------------------------- --------------------------------------------------- 1 FINAL INSPECTION BY: - --- ------ ----- Date_ " 7-.47, ; 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 I Revised 1-57 F:P,CO-