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APPLICATION FOR SANITATION PERMIT Permit No. ................... (Complete in Duplicate) /O/ 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--------•--- -- -----R VO------, ------ ---------------------------------------------------------------•-------- Owner's Name--- --------4i -------•--- "/yS/ ---------- Phone-------------------- Address------------ -1-V---------+_::�A_tf.-------.--�".....I—AV 11<1---------------------------------------------------------•----------------------------------------------- Contractor's Name----- ------ ��--- N-I------ Phone----- •.-- --- Installation will serve: Residence jr-O'Apartment House-E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ---_ Number of bedrooms !lumber of baths___/___ Lot size -------- -----------x(___1_.6_Z?_________-- Water 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 ❑y Clay ❑ Aclobe° e Hardpan ❑ Previous Application Made: Yes ❑ No d New Construction: Yes f[�No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well--- Distance from foundation_ .__1 ______.Material___-___ _. __ !?_________________ No. of compartments___-----1,10 --------Size--- Y--_ __+ _____Liquid depth-----------'-/------------. Capacity Disposal Meld: Distance from nearest well-_. ___Distance from foundation____- _� Distance to nearest lot lin�e�_______________ Number of lines------------LT------------------Length of each line4 -_ --- Width of trench._____a_.9--- ---------------- Type of filter material...../ Depth of filter material__../ f!-____Total length------�__ ________________ Seepage Pil: Distance to nearest well------------__--------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits_. Lining mafierial-----------------------Size: Diameter-----------------------Depth-.------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------......Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-.--------------------------gals. A Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.___________---__----_.-______-_____---__. ❑ Distance to nearest lot line___________________________________________________ -- �e Remodelingand/or repairing (describe):-----------------=--------------------- ------------------------------------------------- ---•-•-----•--------------------------------------•------- -------------------------------------------------------------------=--------------------------------------------••---------•-•----------------------------------------------------•• ---------------------•--------------- I hereby certify that-1 have prepared this application and that the work will be done in accordance with San Joaquin Couniv ordinances, State laws, and rules and regulations 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----- ----- - -- ---- ------------------------------------ ---- DATE----- ----------------------- - , REVIEWED BY---------------------------------1 - -------------------------------. DATE 1 �R ,--�; -------- BUILDING PERMIT ISSUED ,: 'f DATE-------------------------------------- ••-�---------- F Alterations and/or recommend ationi:--' ---• ------------------ f -------------------------------------------------------------------------------��-----•----------- ------------•-------- ...... -----------------------------------------------------------------------------•------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--.-------------------- .- - ----- ..-------------------- -e--- ----- --- - - --•----------------•-------------- ---------------------------------------I- •---•--------------------------------------------- ---------------------- FINAL INSPECTION BY:-- '� ---------- gate .-' -----------=---------------------- 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 )-57 F.P.CO.