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APPLICATION FOR SANITATION PERMIT Permit Na. V` (Complete in Duplicate) 13 s7 Date Issued ------------------••--- _ Application is hereby ma to the San Joaquin Local Health District for a permit to construct and install the work here' described. This application is made �n compliance.wi County Ordinance No. 549. I��i�. �- LX_,r. _ U I— JOB ADDRESS AND CATION--- �o ,� --------- ---- - - Owner's Name -------�r ----- = _ _ aPhone------ Address --- a — Address------------------�-='--`----=-==----- ----------------------------•--------------------------------------------------------------------------------•-- --------•-••----------------•-=---•---------• . Contractor's Name: -'``''Y --- ------ Phone.---- fl Installation will serve: Residence ©Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- Number of bedrooms _:7-- Number of baths __ _ Lot size _____--S� _--_-_ ---- Water Supply: Public system ❑ Community system ❑ Private ®/Depth to Water Table __:----- ft. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe n Hardpan ❑ Previous Application Made: Yes ❑ No � New Construction: Yes 2 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 -------Distance from foundation__.)0: I____GI'.�-� ___ ______________ _ ______Sizes "_�C.fb Li uid de `th1� Ca acit �OOa No. of compartments --- �, q p. P Y Disposal Field: Distance from nearest we]._.Q------Distance fr &I ndat/ion___ -47 _-_ _.Distance to nearest lot line_ __-_.._.- 11-- , rP ' .. Number of lines_______�R__________________ _�_�� Length of each line_______.-_ _____._______ __.Width of trench.---Z- Type of filter material_� /�-Depth of filter material___ length.---f -.-10----------------- � Seepage Pit: Distance to nearest well_____________________Distance from foundation.....................Distance to nearest lot line_______-______._ j] Number of pits------------ ---^--Lining material------------------------Size: Diameter-----------------------Dept h--------------------------------- Y Cesspool: Distance from nearest well____--__________Distance from foundation--------------------_Lining material------------- ---------------------- ❑ Size: Diameter-----r---------------------------------Depth------------=------------------ ------------------- Liquid CapacitYv--------------------- Ic.. Privy: Distance from nearest well__________________________ ______________________Distance from nearest building__________:_____________-'____-+ - ❑ Distance to nearest lot line--------- -D------------------------'--------------------------------- ----------------------------------------------------------------- Remodeling and/or repairing (describe):--- -••-•-------------- -------------- ------ • ----------------- = - ----- - 1 hereb�certify•that I ave pr pared"this application and tha the work will,be done in accordance with San Joaquin Co ordinan ec;s, State laws, and rules 7d r gulations of th San Joaquin Local Health District. (Signed)--- ---.-------- -r------------ --,--- --- ------------- �:(�'�or Contactor]-�- B -------------------------------------------- -------;--------.-- - -----------(Title) --------- . -t_ZA --------4—------- —-------- Y� (Plot plan, showing size of lot, location of system in.relafion to wells, uiidings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY: APPLICATION ACCEPTED BY__ -----------------------•-------- DATE ----------------------------------------------------- REVIEWEDBY---------------------------- _ ` ---------------------------------------------------------------------------- DATE---- ----------------------•------------------------ BUILDINGPERMIT ISSUED-------- --------- ------- -------------------------------------------------------------------- DATE--------�-------------------------------------------- Alterations and/or recommendations:--------------------- ----=-----------._. ------------ ----------------------------------- •---------------------------------------------------------- .._ --•------------------------------------------------------------------------------------------- ------------ ---------------------------------•------•-----•----------------------------------------------------- ------------------------------------------------------------------------------------------------------- -- - -- --- - - - - --------------------------------- FINAL INSPECTION BY:. - Date-----------! .. J � --- ------------------- 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.