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APPLICATTON FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued -------/ 5-- 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 complian e with County Ordinance No. 549. JOB ADDRESS AND�,/LOCATION_ y�� --�-r"'---r.---- _�__�---------- p� v�--�-=-- ----------�-•-------- Owner's Name �r _//_" •rrl------ ° -------------------------------------------------------------- Phone----••-----•---------------•---•---- Address-------------------------------- ---------- -------------------------------- ---------------------- Contractor's ------- . Contractors Name------� ---- ------ --'-------------- 'I rv`L------it4f------------------------ Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ,[�j Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _______ Number of bedrooms -------- Number of baths ___ ---- Lot size __V__ tC .--, •______________________.______ Water Supply: Public system'[-] Community system '❑'- Private III Depth to Water Table ft. Y �r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy,Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: Yes ❑ N9__0 New Construction: YesZ 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 Tank: Distance from nearest well- U__ _�-Distance from foundation_ t:__.._.__,.______. ,B No. of compartments____4;?-:i----------------- Liquid depth._- F ----------------Capacity---Zkt"------- .. Disposal Field: Distance from nearest well__S"�_......Distance from foundation___- '- .._._.Distance to nearest lot line-�"�_:_____ ® Number of lines------/---------------------- Length of each line---6.O- __---___.Width of trench-- 26�_-_'_------------------- Type of filter material____'f%"_ ________Depth of filter material--_ length____ _p_--_______-_-_______-________- a Seepage Pit: Distance to nearest well_;_1G_�-----------Distance from fo ndation_I_n_-____.-_.Distance to nearest lot line_; -0-___.._ ] Number of pits'___ ______________Lining material, y1 __.Size: Diameter__._ 3 =_.Depth- _ - '.________________- � Cesspool: Distance from nearest well_______ _______=_Distance from foundation------------------- Lining material-------------------- -------- ❑ , tSize. Diameter---------------------------------------De th-- ----_------------- -------------------Li Liquid Capacity _ ,..gas. 4� - -%- , - - Privy: Distance from nearest well--------_______; ____,___ ..______:__Distance from nearest building________________________________________ ❑ Distance to nearest'lot line-- ~--------------- . _ r . Remodeling and/or repairing (describe)_---------_------------------------------- I ' V -----------------------------------------------------------•-------------------------•------------------------------------------------------•----------------- L ------------------------------------------------------•---------•-----------------------------•--------------------------------------------- -----•-------------------------•----------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance-wifh San Joaquin County ordinances, S to;,�ws, rules and regulations of the San Joaquin Local Health District. (Signed) y�/ --------- - --------- - -=------------------------------------------------------------------------------------(Owner and/or Contractor) $y:. '' :.- -----------------------•---------------- --(Title)--------------------- -•---•----------------------------------- (Plot plan, showing size of lot, location of system iri relay to wells, buildings, efe., can be placed on reverse side). FOR DEPARTMENT USE ONLY .. APPLICATION ACCEPTED BY--- _ •-'- _ _yA- -� :-- ------------------ - DATE.. -�. . -_. ._7__... REVIEWED BY._.. - ---------`------------- DATE =° =... ---------------------- ------------------ ---------------- BUILDING PERMIT ISSUED------------------------- - - DATE Alterations and/or recommendations-----------------------------------------------------------------=------------------------•------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------•---------------=------------------------- --------•------------------------------------ -------------------------------------------------------------------------------------------=-------------------------------------------------------------------------•------•--------------------------_----------------- ----------------------------------------------------------------- ---------------=--------- ------------------------------------ FINAL INSPECTION BY::_ 'rte 3 "� - -------- 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 . Revised 1.57 F.P.CO.