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Permit No. APPLICATION FOR SANITATION PERMIT . 1........ 1 (Complete in Duplicate) S l a � Date Issued ..7��_..��_.__ Application is hereby made to the San Joaquin Local Health District for a permit toZruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS ANDLOCATION_ l?_L__. 1�'M`f/f� Qi ,I'�itllt- °a------------------- - -------- --------- � ` r Ph Owners Name----<�-/+ � ./ ._..__ ,� -------------------------------------------- --•-- ------------------------- one Address -- ----- - ------------- ---•---•------------ ----------------------------- Contractor's Name � - -- - :2./ •�s� Phone Installation will serve: Residence t partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .`___ Number of-bedrooms S.. Number of baths _/_. Lot Size ----------------------------------- _ _ ((o Water Supply: Public system ❑ Community system �Private ❑` Depth to Water Table'_____._97ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam,❑ Clay ❑ Adobe "Hardpan ❑ Previous Application Made: Yes ❑ No e- New~Construction: Yes gt''No ❑ FHA/YA: 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 71__A`Distance from fo ndation___ -40 _ Mate ial--- _: -- r _ _-_--_. _ Lquid depth_ _ Capacity._ ® ____ -__No. of compartments...4-------------------Size-_>? Disposal Field: Distance from neares well,e�Distance from foundation ./ -_-.Distance to nearest I .f line-, Number of lines------ _I_-r_:_ __Length of each line_!! �'�� _.�./�-.Width of trench `s r Type of filter material 4/r__ Depth of filter material-WY-- ,---®-Total length-- Seepage Pit: Distance t nearest w,eI---Distance o fou ation._�W•-----.Dist rw to nearest o lin __' ___Linin material __ _ Size: Diameter-_,- ________Depth-____ -N•___ Cesspool: Distance from nearest well-----------------Distance from foundation-----_--------______Lining material____-________--_-______-________.___. ❑ Size: Diameter._ -. ____ Depth -_ _ Liquid Capacity_ _____________ ___ _____gals. Privy: Distance from nearest well. .. Distance from nearest building------------------------------------------- - ___ _ ______________ ____ _ ❑ Distance to nearest lot line __ : ti -------------------------------- ---- - - ----- U� - - -------- -- -- rmg (describe) Remode'ng and/or repa� ��----- -- ---�'- -"-`-�--_ ------------------- -------------------•--------------- •------------- "„ „- -----•-----•----------------------------------------- •---- --- ----------------------------------------------------- -------------•---------------------------- 1 ------------------------------------ ------------------•-----------------------------------------------------•---------------------------------------- -----------------•----------- -----•---------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ' ordinances, State laws, d rules and reg ations of th San Joaquin Local Health District. P r Contractor (Signed --- ------- ------ ) )------•--- -- ----- -- -- 1-- -- ------ -- _ --------- --:----- --------------------------------------------(Title) ------ (Plot plan, showing size of , location of system in,relation to wells, buildings, etc., can be plac�on everse e). t FOR DEPARTMENT USE ONLY AP PLICATION ACCEPTED BY---.__-._ -- ----------------- DATE_____---- _ _ 7------------------ REVIEWED ___. ._-- REVIEWED BY '-- DATE --�/ i;l BUILDINGPERMIT ISSUED--------------------------------------------------------------•------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations------- ------------------------------------------------------------------------ ------------------------------------------------------------- ----- r -- - -------------------•---------------------- --------- ------ . _ _- ----- ----- -------- -----_ ---- --------------- ..-------- .. ..... --------------- ----- ----------------------------------------------------------------------------------- -----------------------,-------------------------------- ---------- ------------------------------------ - ,- FINAL INSPECTION BY:._� �------- ------------------ 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 Treyey, California ES-9-2M Revised 1-57 F-P.CO. { - r/