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Permit APPLICATION FOR SANITATION PERMIT No. /►ff .w (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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND OCATION. --- ------------------ - ------------------- Owner's Name --- `----- ----------------------------- ------------------ Phone Address--------;2,z `-- =- ----------- ----------------------------------------= ----------------------------- Phone----------------------------------- Installation will serve: Residence �Apartmen+ House ❑ Commercial ❑ Trailerk Court ❑/Motel ❑ Other ❑ Number of living units. Nu ,ber of bedrooms _ _ Number of baths _�___ Lot size `--a_-_ C ___________________________ Water Supply: 'Public system iCommuriity system ❑ Private ❑ Depth to Water Table __------ ft.' Character of soil to a depth of.3 feet: Sand I] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe tR-- ardpan ❑ Previous Application Made: Yes [] No [ lew Construction: Yes�®--- 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 Ta Distance from nearest we � '_Distance from found tion--- .____..M t rial__.__C---_'__--------____-__ No. of compartments______ _______----------Size___�r�''��Liquid depth ___ _________------Capacity__ f� DispAV osal field: Distance from nearest weiV� -__Distance from foundation _f�/---.Distance to nearest lot li�,___ _ Number of lines....--�___ ._______ _-__Length of each line_______ Q_ _______.W'sdth of trench____ 4�_______._'_.________ Type of filter material_,_- Depth of filter material___:_ _lf__Total length-------/,2G7Z--------------- __ r Seepage Pit: Distance to nearest welly--------------------Distance from foundation--------------------Distance to nearest lot line_-_-_________.___ ❑ Number of pits-`----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Q , Cesspool: Dist &: DameterYnearest-well-----------------Dep+Ince from foundation-------------------Liquid Capacity----------------------------gals. W' Privy: Distance from nearest well---------------------------------------------------Distance from nearest building------------------------------------------ Distance -____-______ ._________Distance to nearest lot line------------------ -------- ----------------------------------------------------------------------------------------- ---------------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- �j - ---------_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 regulati ns of the San Jo uin L I Health District. (Signed)----- - ---<---- `r' y�r (Owner and/or Contractor) 4 � V, t --- By:--------------------- ------------=---•----------------------•-------- -------------------•--- --- - ---------------------------(Title)-------------------------------------------------------------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY y APPLICATION ACCEPTED BY----' --------- DATE----------------------------------- --------------- REVIEWEDBY-------------------------- =----- ------------------------------------------------------- DATE------------------ -�- ------------ BUILDING PERMIT ISSUED = ------------- ------------------------- DATE------_ .. � �t------------------------------------ Alterationsand/or recommendations:-------------- --------------------------------------------------------•--------------------••------------------------------•-------•------------------------- --------------------------•--------------------- ---•-------------------------------------------------------------------------------------------------------- ............---------------------------------------- ---------------- ---------------------------------------==---------•------- ---------------- ------------------------------1____-____1------------------------•-•-------------•-----------------------•----------------•-- t. ------------------------------------- ----••.--------------------------------- ---------- -------------------------------------------------------------------------------- --•--------•-------- r FINAL INSPECTION BY:____ ________ --------------&- � - ----- ---------- -------- - Date-- -----------------------------• - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California F ES--9--2M Revised 1-57 F,P.CO.