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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --- /aa –1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work erein described. This application is made in compliance with ounty Ordinance NO. 54Pr JOB ADDRESS A LOCA,TIO -s -- `---------- •------ Owner's Name ----- -- -----'------- ---------- -- -- ------------------------------------------------ - - -- Phone------------------------------------ Address ' '?^ ----------------------------------------------------------- v"� , ,� Phone._ k Contractor`s Name____ _L4r _ _ I___ ___ _ Installation will serve: Residence Apartment House CoVVVmmercial T i r ur ote Other Number of living units: .__-__ Number of bedrooms _ _____ s _ ___ size _---_ ----------{--------------------------------- Water Supply: Public system E] Community system ❑ Private' 4pth'to Water Table__ ft. Character of soil to a depth of 3 feet: Sanalf—Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 1 Previous Application Made: Yes ❑ NoNew Construction: Yes 6?(_NO ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) Septic Tank: Distance from nearest well---;Q______Distance from foundation__/P__ ___._.Material__________________ ___ _____•------- No. of compartments---- ------------------Size--------------------------------Liquid depth-----------------.--------Capacity- --d-G--- Disposal Field: Distance from nearest well--Q Distance from foundation__/ _ ____.Distance to nearesf,,�eyt_S___ Number of lines-------- Length of each line______3_l�_ ____ Width of trench--- ______ �r Type of filter material_____ Depth of filter material------- -------------Total length------- '_d_-___._________________ __Distance rom fou ation___- v �==-Distance to nearest m _____ Seepage Pit: Distance to nearest well.-`1�d_______ �?�______ __ _. �� __._ Number of pits----- -----Linin material ize: Diameter_ IY3 --------De to _ Cesspool: Distance from nearest well_________________Distance fro foundation__-- -'------------Lining material__._____-_________._ ❑ Size: Diameter---------------------------------------Depth------------------------------------- --------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________._________._______-____ Distance to nearest lot line-----.-----------------------------------------------------------••------------------------------------------------------- 1 Rem eling and/or rep 'ri _(describe)__ --- --,----- ---.-- - -- - ----- - 1 � - - - -•------------------�-- ---f ------------------------- ------------- ----- -- ------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. {Signed)-t_/__. V _..�__ - _(Owner and/or Contractor) ------------------------------------------------------------ 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 REVIEWEDBY---------------------------------------- - - -- --- - - -- ------------------------------------ DATE---- -= •---- ----------------- BUILDING PERMIT ISSUED------------------ ---------- DATE ----------- -- - -- - ------------ -- - - -- ---------------- Alterations and/or recommendations------------------------ ------- -----•---------------------------•---------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- --------- -------------------•------------------------------------------------- ---- ---------------------------------------------------- /_ / 4 - ---------/+ / , FINAL INSPECTION 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 E5-9-2M , Revised 1,57 F.P.CO. w