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APPLICATION FOR SANITATION PERMIT Permit No. --- ---------- --- (Complete in Duplicate) rS Date issued --_.-�-�.1-- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wort; herein described. This application is made in compliance with County Ordinance No. 549. /� t - _/ - ---------------- JOB ADDRESS AND LOCATION---_..-3 7 (.2 Y. -------.5---f• —e-u---- ---- ----__-_([ ��-------•--•- Owner's Name-- ; 1 i-,V-C- --{r -c• 4-------•--------------------- ------------------------------ -------- Phone------------•---------------------- � . Address----------------------------- -------------------------------------------------------------------------------------.._...--------•-------•- - - ---------------------- Contractor's Name---------------------------- ----- ---------------------------------------------------- Phone } Installation will serve: Residence Apartment House ❑ Commercial [-] Trailer Court [I Motel ❑ Other ❑ Number of living units: __. ---- Number of bedrooms -3__ Number of baths _I---_ Lot size ---�----X-----'--•Y------------•-• ------- Water Supply: Public system;` Community system ❑ Private ❑ Depth to Water Table Ff_ ft. Character of soil to a depth of 3 feet: Sand F] Gravel E] Sandy Loam El Clay Loam E] Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes No N. New Construction: YesK No ❑ FHA/VA: Yes ❑ No�` t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wells 219---_,Distancefromfxoun n----/0---.---MateOl_ - -- - -- -- ---------------- Size- --- No. of compartments-..�---------- ---Size-- ---r`-- 1- --- -- Squid depth-------- ----=--------Capacity------ C� Disposal Field: Distance from nearest well- ----_ Distance from foundatio r __D_.___-.Distance to nearest lot line-.--CS_-_--_f [ Number of lines-----_--- - Length of each lin - -,�- --a--- -3-. s1f f trench------------ -----------------•-- I T Type of filter material- '� Depth of filter matena _------Total length---/- - -------------------------- Seepage Pit: Distance to nearest well-- _- -__---Distance from foundation....................Distance to nearest lot line--.-.-___--- - ize: Diameter--------------------_--Depth-----.----------------•------- ❑ Number of pits---------- -----------Lining material-----------------------Sf, + W Cesspool: SD�zea Diameter_nearest well-----------------Depth Ce from foundation Liquid Capacity----------------------------gals. y Privy: Distance from nearest well. _-------- ---------------Distance from nearest building--__ --------- -------------- ------- ❑' Distance to nearest-lot line------------------ ----------------------------------------- -------------------------•---------------------- --------------- r I Remodelingand/or repairing (describe) ------------------------------------------------------------------------•------------------------------------------•-----•----------------•--•----� ------------------------------ -------------------------------------------------------------------------------------------•-•-------------------------------- -------------=----------------------------------.... ----------------------------------------------- L 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.(Signed < —-----X LJ� - ------_---(Owner and/or Contractor) B - - (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------------- ------- ------------------------------------ REVIEWEDBY---------------------------- Y ------------------------------------------ DATE------ BUILDING PERMIT ISSUED-------------- ---------- DATE �---------------------- ------------------ Alterations and/or recom end tion ----------------- -- �. ---------------------------------__--------- .- p J . .-_. '''`1R• - - '------- 5�- `� a ----- 67 .------------------�----- ----- ----------------•------ -------------------------------•-----------•-----------•------------------- f QatIf FINAL INSPECTION BY:__ .-. ,.-. =-- `------ ---- �/ ----------------------=------•------ SAN JAQUIN 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 , Revised 1.57 F.p,CO-