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APPLICATION FOR SANITATION PERMIT Permit a (Complete in Duplicate) Date Issued .!--__{ 7 ' This Permit Expires 1 Year From 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. 5 9. JOB ADDRESS AND OCATION----- 17 u - -- -------- �''�c,.. •`� .@. Owner's Name___ - - --- vat -f------------------------------ Phone----••-------------•--------------- Address-------------•----------•-_-4- 21. �- --- ----"-•--------•-----•----------.... }Contractor's Name-- )&---T-l�llr-.....-----��®�r'^ ----•-------•------- Phone. ............ Installation will serve: Residence Apartment House ❑ Commercial ❑ Tr ' r Court ❑ Motel ❑ Other ❑ Number of living units: _�__._ Number of bedrooms _ - Number of bat -.-- Lot size _ -- G "----------------•------- Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table _ ___ ft. Character of soil to a depth of 3 feet: Sand 0/Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe❑ Hardpan C] Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewgr is available within 200 feet.) _. . Septic Tank: Distance from nearest well__d nce from f undo ion�d_' aterial____ ___ ____----________�.__________- No. of compartments------ �� _:---{--------Size__ 1 -�/'�- .� _ iquid d�epthr--- ------._.Capacity----)2_40-op--- K. Disposal Field: Distance from nearest weL_�� stance from foundation, �r �'+�"'�istance to nearest lot I'n I Number of lines---- Length of each line--- --- V - Width of trench___e�. __,_ "� -- ---------- Type of filter mater�al____._t epth of filter material____-_ __ ____Total length_____ �__. .________________-.__ l Seepage Pit: Distance to nearest well---------------- from foundation_________________ Distance to nearest lot line_---__.._______-_ ❑ Number of pits----------------------Lining material-----------------------Size. Diameter----•-----------------Depth--------------------------------- Cesspool: Distance from Irearest well----------------- from foundation------------------- Lining material___.___...____.____---__________.___. ❑ Size: Diameter-1-----------------------------------Depth-------{--------------------- ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well__..____.___...__----__________________________Distance from nearest building----------_________________----_-__._-__. ❑ Distance to nearest lot line------------------------- ------------------- -------------------------------------- ------------------------------------------------------- Remodeling and/or repairing (describe):____-— '} ----------------------------------•-------------------••------------ _______________________________________________________________________________________________________________________ 'L I hereby certify _ _-that I have prepared this applicatian and that the work will be done in accordance with San Joaquin County 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 t, location of system in relation to wells, buildings;,btc.4can be placed on reverse side). a � r .. F DEPAVWNT, E ONLY ,14 APPLICATIONACCEPTED BY----- P -- ------- -- ------= :--------- T E REVIEWED BY------------------- ----------------------------- -----------------------------------------;-------- DATE------------------------------------------------ ------ -------------------- -- BUILDINGPERMIT ISSUED--------------------------------------------------- ------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:-_--___.___._..._._ I -=-- -----•-•------------------------�-- "�'w^^r-..•...o- 4 + --"----"-"----•-------------------•--•---------"-------------------------- FINAL INSPECTION BY:--- --- 1 �# --- ---------------- Date - SAN JOAQUIN LOCAL HEALTH Di.STRICT 130 South American Street 300 West Oak Street —132 Sycamore Street 814 North "C" Street S+ock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised V59 F.P.Co.