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APPLICATION FOR SANITATION PERMIT Permit No.,ell ___Q_-_!_- •¢.--__ (Complete in Duplicate) 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, JOB ADDRESS AND LOCATION...... �,, / -------------------------------------------------------------------------------------------------- Owner's Name ---. f ��'/- rC/-----------------•-•- -------- Phone--------------------"---------- Address----------- / LQ .- --------- -------- ---------- Contractor's Name------ -- --------- J ----------- Phone-------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units: __ _ Number of bedrooms _ __ Number of baths Z_. Lot size ___4�_ _�____ ------_-______________________ Water Supply: Public system P__61mmunity system ❑ Private ❑ Depth to Water Table -------- ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Applipation Made: Yes ❑ No &' New Construction: Yes ❑ No UprFHA/VA: Yes ❑ No W5--- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 00 Sep _ I'stance from foundation-----/V _ V--------- ral__� r Septic T�: Not of compartmentsmt_S---------- - z6l;104 K__ eIj�__ Liquid d � epth-- t---------------Capacity- Disposal apacity-- DisposalFeld: Distance from nearest well_7 Distance from foundation_lg______ _.Distance to nearest lot.li e_—____-- f Number of lines-------_ Length of each line____.�1 _.___ Width of trench.___ _�________ Type of filter material Depth of filter material-- -----__"_---Total length-----, ------ ,� "" Seepage it: Distance to nearest well__'jZDistance from fo dation-__f _•----.Distance to nearest lot linean----------- Number of pits___---------------Lining material��_ ` .Size: Diameter---�.�_♦i_---------Depth----��'�____- ------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- 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):-------- �r='�------ --- --------- t 4 IL ------------------------------------------------------------------•---------------------------------- --------------------------------------------------•------------------------------------- -------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------------•----•------------------------ o n - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County A ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. v � (Signed)-----------_ -- - ---------(Owner and/or Contractor) BY:------------------------------------ a -! -----------------------------------------(Title)--- --- ------T-------- (Plot plan, showing size of lot, locaf' of system in relation to wells, buildings, etc., can be placed on reverse e]. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------------------------- ---- --- ------------------------------------------------------ DATE----5 ----------------------------------------------- REVIEWEDBY------------------------------------------------------ - --- -------------------------------------------------- ------ DATE---------- BIJILDING PERMIT ISSUED------------------------------------ - --------- DATE---------_.- _- Alterations and/or recommendations----------------------- --------------------------••-------- ------------ - - --------------------------- ----------- - ----------------------- -- ------------------------------------ "�-�Z� ........... ------------------------------------ -----------------•---------- ---------------------------------------------- -----------------------•-----------------------•---------------------------------------- FINAL INSPECTION BY:. ----------------------- ------------- Date-------------- 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 F.P.CO.