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. v APPLICATION FOR SANITATION PERMIT Permit No. ..f_ . /1 (Complete in Duplicate) pate Issued ----616- - This Perm -it Exfres 1 Year From Date Issued plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. • pp p y Ordinance N�� 549. This application is made in compliance with Count Ordina JOB ADDRESS AN CATION-- -�------- ------------- Owner's Name----------- YZ) C --------------------- ------ - Phone---- •------------------------------ , ' Address--------- ----------- ------ -- Contractor's Name i~ ------------- Phone Installation will serve: Residence Apartment )-louse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ /Other ❑ Y Number of living units ` "'' Number'of bedroomsNumber of baths - _-__-- Lot size ---•---------------------- Water Supply: Public system Community system ❑ ,'Privates❑ .„;Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Cli y-Loam,❑ -Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ Nord\ New Construction: YeNo E] FHA/VA: Yes No� r� I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if;p blit ewer is available within 200 feet.) FF , Septtilo'Tank: Distance from nearest well-- ---__Dista e from foundation-------L�----.Mat ri�l_ .. -- --- --------- {� No. of compartments-: �y=___.fze .��-��--Liquid dept-------�-.---_-_.--Capacity----- - _-- Disposal Field: Distance from nearest velli- ----Distance from foundatio ----- f --_-_.D{stance to nearest lot lige----------------- Number of lines_--'__- Lt Length of each line------ --fir-- ----Width of trench.--_--C�------------ --------- . Type of filter material----Z2---F_f epth of filter material_---- --- ------_Total length--__-.---z�0-----------_----_-_.-. Seepage Pit: Distance to nearest we'll- ------------------Distance from foundation--------------------Distance to nearest lot line----------.------ 1 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- CA Cesspool: Distance from nearest well-------_-----_Distance from foundation------------------- Lining material___.---------------------------....... ` ❑ Size. Diameter-------------------------------- =---Depth--------------------------------- ---;--Liquid Capacity-----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building----------------------------_--------.--. ❑ Distance to nearest lot line = - - =-------------------------------------- ------ Remodeling and/or repairing (describe):------ -- — -- --"- --------------------------------------- ----- ------------------------------------------------------------------- -- -----C--------- w ------------------------•------------------------------ ------------------------------------------------ ------------------------ ------------- --------------------------------------------------------------------------------------------------------------------------------------------------------- I ------------------------=------------------------------------------------------------------------ I hereby certify that I have prepared this lication and that the work will be done in accordance with San Joaquin County ordinances, State I ws, and rules and r s of the San Joaquin Local Health District. --------- -------------------_----------------------------.---(n-(Ownernd/or Contractor) (signed)--- - -=- ---- -------------- - -- ------------ - $Y= --•-•----------------------- ------------------ ---------------------------------------------------------------(Title)--------- -------------------- --------- --- ------------------- (Plot -- -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.f can be placed on reverse side). w FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- -------------- k - - -------- -- -- ------------------------------------- DATE--------- ------------------------------ REVIEWED BY---------------------- -- DATE- - -------------- - ---------- ---- - - --- ---- - -------------------------- BUILDIN -------- --- ---------------------------------------------------------- DATE Alterationsand/or recommendations------------------- -- -- ---------------------------------------------------------------------•--------------------------------------- ------------- -------------------•---------------------------------------- ---------------------------------=------------------------------------ ------------- - ------------ -- - -------------------------------------- f +i --� FINAL INSPECTION BY.-- Date_ 7—S SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street t + 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Es-9-2M Revised 8-'59 FT Cc,