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Y APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) E 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 LOCTION__________ et Owner's Name ( ---------------------------------------------- ------- -- Phone------------------------I=---------- .. Address------------ - ---••---------- ------- .....: -- --------------•-------•-------------------------------------------------- ---------------- Contractor's Name-------__ cr ---s --------- ---- r Phone. Installation will serve: Residence A artment House ❑--Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: `Kumla r-of'. edroorris _____-.:Number of baths __ _,_ Lot size _______ ___ ___ __ _ .____,_______ Water Supply: Public system Community stem ,El Private[] Depth'to Water 1ao�e Character of soil-+o a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ C a�y Loam `GSI y`fl I�coije `Ha'rt rl-[],. s "I Previous Applica+ion�Made: Yes ❑ No ❑ New Construction': Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- (No( septic fank or`cesspool permitted if public sewer is available within 200 feet.) �f , Distance from neareSeP ic�Tk: st well__ _______ Distance from foundation---- -0___-___Material____ No. of compartments---_------�.�-----_..Size-___y, _______---__.Liquid depth--------------------------Capacity-e0-0 Disposal Field: Distance'.from nearest well_M0_'__-_Distance from'forundation,.:� ----------Distance to nearest lot line._____.-. ©/ Nj umber of lines____'.1—---------------------Length of each like---- __-- -------.Width of trench---:11—y�_______-_---____________ -� Type of,fiiter material--- 4'_Cr�_ -___-Depth of filter material----/_------------Total length--------------------f. ______-- w Seepage Pit: Distance; to nearest welL_____:_:J__--_--__c_-Distance from foundation--------------------Distance to nearest lot.line_:____-________-_ lv " " [] Number;of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- esspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____._---__________________________- 0 _ Size: Diameter-------------------------- ---*------Depth----------------------------------------------------Liquid Capacity----------------------------gals. I y: Distance. from nearest well----------------------------------- --____Distance from -nearest wilding____________________________ ------------- ❑ DistancE to nearest lot line - ------------- -------------------------------------------------------------------------------------------------- ----------- Remodelinand/or repairing (describe)----------- 5QM_I ----- -~- �_ / ------4-F-4.4--c- ------- 9 � ` - ------------------------------------------------ -- I hereby certify fha+ I have prepared this applice+ion and that +he 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) g } � �� -- ----------- =------------------ -----------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------- ----(Title) (Plot plan, showing size of lot, location of system in .relation-fo wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- z:--f--------------------------- ----•----------- DATE------ REVIEWEDBY------------------------------------------------------------=-------------------- 5-1------------------------------------ DATE------------ •-----------•------- BUILDING PERMIT ISSUED --------------------- ----------------------------------- DATE Alterations and/or recommendations:-------=------- '---- F ----------•-------•--------------------,-----------------------------------•-------------------•--- --------•-----------------------------------------------------------.- -----------•--••-----•-•----------•------------•----------- ----------------- ---------------------------------------------------------------------------------------------------------------------------------- V ----------------------- -----------------------------------------------•--------- -------------••---------------------------------------------------- - ------- - -------------------------------- FINAL INSPECTION BY--------------------------------------------- Date--.----------i-_,F- 3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak street 132 Sycamore Street 814 North "C" Street s. Stockton, California Lodi, California Manteca, California Tracy, California ES---4-21x1 Revised 1-57 F.P-CO_ � .,,