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APPLICATION FOR SANITATION PERMIT Permit No. . y--7�-__.- (Complete in Duplicate) 7/1 Date Issued ------=---------------- i 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. r } JOB ADDRESS AND L ION--; --------f---0-.a----9-------1-511------- Owne'r's Name -- --/t!'>--lC--- ---- ------------ Phone------------------------------------ Address---------- ------ --------- Contractor's Name---------- ---- ------------------------ a' Phone •-------------- 1 w Installation will serve: Residence Apartment House ❑// Commercial ❑ Trailer Court [] Motel ❑ Other El Number of living units: f- ----- Number of bedrooms _-1_.-_ Number of baths -/_-_ Lot size - _��-------------------------------------- Water .�� _ 1 ----------------- Water Supply: Public system ❑ Community system ❑ Private VDepfh to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ ravel [❑ ' Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe 10--nardpan ❑ Previous Application Made: Yes ❑i No New Construction: Yes [ fo 0 FOIA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted-[# public sewer is available within 200 feet.) Septic Ta Distance from nearest well 15-Q._---- Distance Jrom foundation_-- d----. -.Material_ --_ No. of compartments--_-.-r '__ i ui / yy ---------Size---- --- -v------rt---- q d d�th-�---- -----------Capacity-------------- �'f- - - Disposal F• Distance from nearest welt---,6"�V_-._Distance from foundation-- -_ -_ r_--.Distance to nearest lot li�___ [ Number of lines---------/. .<---------------- ength of each line---------- - Q_.-_- _--.Width of trench.-__�_ __� !! ,, ------ -- Type of filter 'rndterial_1 ----- epth of filter material------4 - length-- ____------------------- Seepage Pit: Distance to nearest well--------------_-------Distance from foundation---.----_____---___.Distance to nearest lot line__------------__ ❑ Number of.pits-"1-------------------Lining material------------------_----Size: Diameter-----------------------Depth---------------------- o� Cesspool: Disfance-from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- El Size: Diameter---- ---------------- -------------Depth------ ---------------------------------------------Liquid Capacify----------------------------gals. V Privy: Distance from nearest well----------------------------------- ------Distance from nearest buiiding----___.-------_---------_- ❑ Distance to nearest lot line------------------------------------------•----------------------------------------------------------------------------------- ------------- Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------- --------------------------------------------:-------------------------------------------------------------.---•--------------------------------------------------------------------------------------------------------------- --------- -------------------------- --------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work mill be done in accordance with San Joaquin County ordinances, Stats, an es regulations o t San Joaquin Local Health District. 1 (Signed)____.__7 --f------ -- . . ; t -------------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------------- -----------------------------------------------------------------------------(Title)-------------------------------------------- -------------- ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- -------- -- ---- ---------------- -- ---------------------------------------- DATE- ---------------------------------------------�` REVIEWED BY - -------------- DATE------- Al ILDINGPERMIT ISSUED--------------------------- - --------------------------------------- ------------- DATE----- .� --------------------------------- - --------------------------- Alterations and/or recommendations: - ---- --- ------- ------------------------------------------------------------------------------------ ------------------------------------------ --------------------------------------------------------------------------------------------------------------------------- a FINAL INSPECTION BY____All __ Date 7 r- /4C —5 ---------------------------------------- -- SAN JOAQUIN LO AL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M. Revisea 1.57 F.P.CO. i