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APPLICATION FOR SANITATION PERMIT Permit No. _1103___---_ (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 LOCATION,—.'?r3, __9______y__-/��,_____ _ ___ _ f (� ----------------------- .... Owner's Name------------- /,� � -p't f"�- -- ------ ,...: ---------------------------- --------------------- Phone--------------- d Address .... .... ------f.(l-' s Contractor's Name--------------------------------------------------------------------------------------------------------------------------- ---------------- Phone------------------------------------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑I Trailer Court ❑ Motel [❑ Other P - r Nurriber of living units: In_ Number of bedrooms--3___._ Number of baths _./__-- Lot size _x..��-----_____________ Water Supply: Public system g] Community system ❑• Private ❑ :Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe ErHardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ® ( osept'c tank sp p publicis sewesaealao available within 200 feet.) Septic Tank: Distance from nearest well-- Distance foudation•J___. Material-_. --±__..-_._- . No. Il of compartments______.___f _ ----------Size--- 1 __`? ''� 1 - ,_._Liquid depth Capacity '{-�-�-- Disposal Field: Distance from nearest well..............Distance from foundation----I_�_—Distance, to nearest lot © Number of lines--------- ':_'":,__________Length of each line____-_`� ------------Width of trench--- - - __.._______..___ Type'of-filter material___ _ � �� _Depth of filter material-----/k`!___-_._Total length------- /_-d_------- Seepage Pit: Distance to nearest Distance from foundation----....___.-------Distance to nearest lot line-_ ZNumber of pits------d''`-_tr-----Lining material-l-__� e_lrC_ Size: Diameter____ - --------.Depth--r�``^�d------------------ a. - - 4 n Cesspool: Distance from nearest well------------------ from foundation------------------ Lining material________________ _____________- �7 ❑ Size: Diameter------------ --------------------_.Depth-------------- ----•------ ------Liquid Capacity---------- -------gals. Privy: Distance from nearest well---- ----- - from nearest building---_______._____________________--___.._. Distance to nearest lot fine----------.-------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------- ----------•-------------------------------------.------------------ ------------------------------------------------------------------------------------------------- `. ------------------------------------------------------------------------- -------------------------------------------------------•-----------•----------------------------------•-------------- 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 regulations of the San Joaquin Local Health District. (Signed)--� `"`." +. -- ---------------------------------------------------------------------------------- ------(Owner and/or Contractor) BY-----------------------------------------------------------------------------------------------------------------------------------(Tifle)---------------------------------------------------------------- (Plot ------------------------------------(Title)------------•------------------- ------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 4 /,,.FOR-UEPARTMENT USE ONLY APPLICATION ACCEPTED ; - , ------ DATE /f REVIEWEDBY------------------------- ---- --------=------------�------------------------------------ -------------------------- DATE-----=---1------ BUILDING PERMIT ISSUED------------------------------------------------------------------- --------------------------------- DATE-------- ----------••------------ i Alterations and/or recommendations:-- ------------•-----------•-------------------------------•------------------------------------------------_-------•-•-•--•---------• --•------- r _---------------- ----------------------------------------------------- -•------------------------------------------------- ----------------------------------------------------------- ' ---------•----------•-- ---------- ----------------------------------------•-• -------------------------------------- --------------------- -------------=------= t--------------_------------------•---------- ---------------- - ` - c --_ . l -- FINALINSPECTION 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 Tracy, California ES-9-2M Revised 1.57 F.P.CO.