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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 6141_Z_7 Application is hereby made to the San Joaquin Local Health District for a permit to c rust and install the work herein described. This application is made in compliance with County Ordinance No. 549. n JOB ADDRESS AND L02-TION - -----_ _d !If - --•--- e wner s Name----- .- ----------------------------------------- ----- Phone------------------------------------ Contractor's Name.-----.. ----•---------•----•-------- ---_----.-_-__ ------------------------------------------------------------------------------------------ ------------------------- - Phone Installation will serve: Residence ry Apartment House ❑ Commercial bati El Trailer Court El Motel E] Other El Number of living units: D?--_ Number of bedrooms ._ -. Number of baths _W__ Lo} size __-�� ? -------------- ater Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ .Sandy Loam ❑ Clay Loam El Clay ❑ Adobe Hardpan �] Previous Application Made: Yes-19, No [:1 New Construction: Yes'❑ No�PHA/VA: Yes ❑ Noo TYPE OF INSTALLATION AND SPECIFICATIONS- ; (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic ,nk: Distance from nearest weft-----------------Distance from foundation-------------------- " / � Material_------------------------------------------------ I -- _ p No. of compartments---- !! -- S Liquid depth--- ---- Ca act Disposal Field: Distance from nearest wel. _- ___ sante r o n a ion-- _ • � ___.Distance to nearest lot line--- s Type Number filter material---� Length of each line-------7i7_-- Width of french---,-? umber of lines----__ ' _____ _ �� --Depth of filter materia---_- f' ' -� - - ------Total length-----�_-- --�----- -------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation___•----_--_._-___. _Distance to nearest lot line----------------- Number of pits----------------------Lining material-----------------------Size: Diameter-__--------__._ - ------ Depth-------------------------esspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---__---------_-----_----_ FI Size: Diameter------------------ -------------------Depth-----------.------------------------ --- Capacity - ---- -----Liquid ---------- --------- ------gals. 1 Privy: Distance from nearest well------___-.-_ ---- -----------_---------_-_--__Distance from nearest building1 ❑ Distance to nearest lot line ---------------------------- Remodeling and/or repairing (describe)----------- ------------------------------------------- --------------------------------------------------------------------------------- ------ -------------- ---------------------------------------------•------•----------------•---------------- ---------------------------------•-------------------.---------------------------.------•-------------------------------- 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 regulations of the San Joaquin Local Health District. {Si ned 9 ) ------------------------------- ------------------{Owner and/or Contractor] By:_--- :------------------------------ Title (Plat plan, showing size of lot, location of system in.relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------.__--__ --- - ----- -----------•---------------------------- DATE--------------------- REVIEWI=D BY = DATE-- �( BUILDING PERMIT ISSUED------------- / T J. --- ------------------------------ -------------------------- DATE.-------.---- --------------- Alterations and/or recommendations:---------------------------- -------------------f = ---- -- ------ -------- A��; f _�n �co i ---------------------------------------------------------------- -------------------------------------- ----------------------- FINAL INSPECTION BY---------------------- - I ct1�, ' ff jl Date - C ---------------- SAN JOAQUIN LOCALHEALTH DISTRICT 130 South American 5+root 300 West Oak Street 132 Sycamore Stree+ 914 North "C" Street Stockton, California Lodi, California Manteca, California + Tracy, California ES-9-2M , Revised 1-57 F.P.CO. }