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APPLICATION FOR SANITATION PERMIT Permit No. . Q-l.}�h (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 This application is made in compliance with County Ordinance No. 549. DSg - GO--C,6 `�` • == r A-4a,�k— �- !�. . JOB ADDRESS AND LOCATION---{--- 1---- ---- - - Owners Name----- ---- -------- --------------------- ----------- ------ Phone------------- ffF - Address_._... ----------- ------------------------------- Contractor's Name------- ------%.'U-t'-^---,r^-= '=-A-R-------------------------------- ------------------------------ ---------------- Phone----------------------------------- - Installation will serve: Residence LI—Apartment House E] Commercial ❑ Trailer. Court ❑ Motel ❑ Other ❑ Number of living units: _ _.__- Number of bedrooms ---Z,:�Number of baths .... Lot size ____ _ { __ - rs --------------------------- Water Supply: Public system E] Community system ElPrivate ®Depth to Water Table 60, ft. Character of soil to a depth of 3 feet: Sand L] Gravel F1Sandy Loam E] Clay Loam ❑ Clay E] Adobe []",-Hardpan F] Previous Application Made: Yes ❑ No ❑<New Construction: Yes O'_�N_o ❑ FHA/VA: Yes ❑ No ❑�'� TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) v . Septic Tank: Distance from nearesfi well_- �__ __Distance from foundation__+)____----___.Material_____- h.�--- ---------------- No. of compartments-----�---------------Size.'-"A__.?:5----��_�__c:.:_Liquid dept} �' - Capacity----� - ,- ------- Disposal Field: Distance from nearest well.,!__1._L',_.Distance from foundation__)!!_--___-_.____Distance to nearest lot line____----------- Number of lines____-..�-__..._____. Length of each line------- _'1l__�_��____.Width of trench_._1_,-- --------------------- ---------- Type of filter material____I�i•� -----_-Depth of filter material_._.____if-+---------Total length .�_____________________ � 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- --------------------------gals. -- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building________.__.--------_____________-.----. ❑ Distance to nearest lot line--------------------------------------- ------------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe}: {-�( �2`' C G ci? °� _{ �r�• --- --"'-------- �i_�w�------- 3 ------------------------------------------------- ----------t=° -~`-----;----------------------------------------------------------------- t -----------------=---------------------------------- ------------------------- .b i -- - - -- ------------------- --------------------------------------------------------------------------------------------------------•-------•------------------`---•---------------------------' 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin.Vocal Health District. �_�-- � /Y�� -.. - � ----------'------------- ----{Owner and/or Contractor) (Signed)_ ._-,lam'.��'_�:r-------: max- �---------- -----� -- --- 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------------------------ ~ 'r -` ----------------- ------------------ DATE---'- ----------------------------------- REVIEWEDBY------------------------------------ ------------------------------------------------------------------------ DATE 1 BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------- ------------------------------------- ---------------------------------- --- -------------------------------------------------------------- } � _ -------------------------------------------------- � __________________________ -----_____________________-.-------------------- _ ---------- -------------------------------i, !°i.�' ------- -- --------------------------------------------------------- ------ ----------------------------------------------- - ------------- ----------------- -------------------- ----------------------- ----------------- -- FINALINSPECTION 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.