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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) 1(/ Date Issued .Z5 3—azo —r,? Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This_.applicationris_made-in-compliance--with-County Ordinance No. 549. JOB ADDRESS ANDOCATIONG. _. Aef Owner's Name ----- --- ---- ---- --- ------------- ---- -- - ------ Phone Address---------t � r�r --" Contractor's Name--------- -- - -- --- ---- ----------------------------------------- ---------------- Phone.-.------------ --------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ------ Number of bedrooms ________ Number of baths -------- Lot size __1_"_]_______�__.___ __ ' ____________ Water Supply: Public system ❑ Community system ❑ Private^T Depth to Wafer Table _/_ tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Har pan ❑ Previous Application Made: Yes ❑ No 0 New Construction: Yes [ o HA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 f et.) Septic ankance from nearest well)-57 Distance from foundat on _dzb_ __-Matetn lo. of compartments---�r-----------------Size__, __ >�j- de}?th------ --------_---Capacity--2� cQ----- Disposal Field: Distance from nearest well---l6__Z9Distance from foundation------3-_-,1S*'___.Disfance to nearest lot Iinv_OA Number of lines_____________ _______ Length of each line-------7f-_______________Width of trench___Z ____._______________ Type of filter material��- Depth of filter material--------1.9________Total length______ Seepage Pi Distance to nearest well-----t_g-o—Disfance from foundation---h..Q-------Distance to nearest lot Number of pits--- ---------------Lining ma ____________--- ize: Diameter------- �__-. rp+h_ .Q -_� � Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material________________________--------___ 1 ❑ Size: Diameter------------------------ -----------, -=Depth----------------- ---_----------Liquid .Capaci.ty--=------------- 9r a�s.�c�'� v �- � , Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------____..__ ❑ Distance to nearest lot line------------------------------- - --- ---------------------------------------------I-------------------------------------------- fr r r Gb Remodeling and/or repairing (describe)..__ !------------------_ Q-rid--• - ----- VQV ------------•----------- - --- -------- ----------- -------•---- -- ------------- -------- ---------- ----------- ------- ------------ = - ---------------- ------------ - 1� 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)--- ------- ----------------------- ----------------------------------------------- Contractor] BY: ---------------------------------------------(Title)---- (Plot plan, showing size of lot, locatjio0isysZern in relation to wells, buildings, etc., can be placed on reverse side). l FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----------- DATE_- REVIEWED BY---- --------- --------------- =-------------- DATE-- ! BUILDING PERMIT ISSUED_------------ ----•--------------------------- ------------------------------------------------ -- DATE Alterations and/or recommendations------------- ---------------------------------------------------------------------------------------------- -------------------•------------------------------------------------------------------------------------------------------------------------------------- --------------------------••-------------------------------------- ----------------------------------------------•--------•-------•---••---------------------------------------------------- -------- -----------------------------------•------------------------------------------------------ FINAL INSPECTION BY--------- ---------- ----- ----- --- Date r0 - 1 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_