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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ___.I_______I -..--- 1-7 920 3 Y 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. S49.� . -,E � 04G ADDRESS AND LOCATI NW------ JO - —--_1e9— JCt � • ------------•------------•----- ° '"---------------------------- Phone ------- Owners Name---------------••- ---• ---•--- ---�'F -- -------------Address.-----------••--------------• - Contractor's Name-------------------------- - ------------ -----------------------------------------------------------• Phone----------------------------------- ------- ----- - ------- ------ - - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ,❑ Motel 11 Other IN ,q .J.,-,e Number of living units: __Z__ Number of bedrooms -/-. Number of baths _2___ Lot size ____ -lY------:•-•----,•--------•-------- Water .Supply: Public system ❑ Community system ❑ Private [Er"'Depth to Water Table __ __ ft. Character of soil to a depth of 3 feet: Sand E] Gravel 171 Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan❑ l Previous Application Made: Yes ❑ No [ New Construction: Yes PrINo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet} �}y Septic Tank: Distance from nearest well__�,'.J_---------Distant from fou dation_!-f! "`'Maerial________ ______!__ _�___ '�•-` Size_ij __ 13 �Y------Liquid depth---1-�----------- Capacity_ T1`.�----- No. of compartments----------------- �- / -h9 ---Distance to nearest lobine__-- - t Disposal Field: Distance from nearest w/�ell_�Z________-._.Distance from foundatio � 1A Number of line s___________10-- ___. A___Length of each line-------- __�_____________-Width of trench.--__ _____� ------------------ 40 Type of filter material--!5t __ ____--_Depth of filter material---- ______Total length___-_ ____ _____________________•-- Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line----------------- 0' ❑ Number of pits------------------ ---Lining material-----------------------Size: Diameter-----------------------Depth----------------------- ---------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material-____--________-___________-_____----. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. r-- Privy: Distance from nearest well---- -------------------------------- -----------Distance from nearest building-----------------------------------------. ❑ Distance to nearest lot line--- ------------------ ---------•---------•--------------------------------------------------------- ------- Remodeling and/or repairing (describe):-- --- ---------------------------------•--------------------- ------.-__�----------------------------------- { r ----------- ---------- --------- ------ --- -- - --- ----- - I hereby certify that 1 have prepared this application and tha+ the work will be done in accordance with San Joaquin County ordinances, State laws, and rul sand re uI tions ofAhe San Joaquin Local Health District. ' _ ______________________________(Owner and/or Contractor) l (Signed)--------- Y Title (Plot plan, showing size of lot, location of system in r Vfion to wells, buildings, etc., can be placed on reverse side). E F R PARR ENT USE ONLY ^ � ------- K APPLIAON ACCEPTED BY____ __ __ _________ ___ c < ------------------------- DATE REVIEWED BY--------------------------- ------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------- ----------------------------------------------------------------------- DATE.--•--------------------------------------------------------- Alterations and/or recommendations:----------------------------------------------------------------- --------------------------------------------------------•--------•-__-------------------- --------------------------------------- ----- -------------------- ------------•------------- --------- FINAL INSPECTION BY..- Date-----l- ----------------------------------- 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 . Reviseci 1.57 F.P.CO. ,.