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APPLICATION FOR SANITATION PERMIT Permit No. .__l.. -9------------ (Complete in Duplicate) Date Issued e Application is hereby made to the San Joaquin Local Health District for a permit to cont ct and ins �,•the wort i rein dgscribed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION...----------- _ '`1__ . _ _ �^ -.--------- Owner's Name---------------------- -- ---•--C -f---- r------------------------------- Phone--_f.._4__n- _l Address.......-------------------•---•-''------------------------- ----- �G� ��r� `' � �-------------��--------------------------------------------- Contractor's Name----------- ....L. Phone ---------------------------- Installation will serve: Residence X Apartment House ❑ Commercial ❑T Trailer Court ❑ Motel ❑ Other ❑ Number of living units:, Number of bedrooms _2--_ Number of baths,._ Lot size _______1r�SX_� 3 ______________________ . f Water Supply: Public system ❑ Community system ❑ Privatej Depth to Water Table ft, i Character of soil to a depth of 3 feet: Sand ❑ -Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ l Previous Application Made: Yes ❑ No New Construction: Yes No ❑ FHA/VA: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel Distant from foundation___--_________.M iaf_____________________________..__�_.._______ --- - 1 -y - `. No. of compartments__'__ ____-_____Size_ X _ _Liquid depth__.____._®______Capac�}y___l-- Q-a isposal Field_: `'" Distance-from nearest well.......}.Distance from foundation---J_d-------_Distance to nearest lot line--_-_S_ Number of lines___________ Leng}h of each line--------A10_d:�?A-.Width of trench_____. �'�`r___._. _ r Type of filter material ____ __ epth of filter material---------11R-------Total length___._.._-- � �---� Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line_______________._ ❑ Number of pits----------------------Lining material----------------------.Size: Diameter------------------------Depth------.-------- ------.--_------- Cesspool: Di0ance from nearest well-----------------Distance from foundation_-------------._._Lining material________.______.____,________________- �/ 0 Size; Diameter--------------------------------------Depth-----------------------------------------------.-_-Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest bui{ding-----__-_--------______-_______________- �❑ Distance to nearest lot line - ----------- - ---------- -----------•-------------------------------------------• - ---------- ---------------------------- .- Remodelin and or repairing describe : __ _- ---------------------------------------- ----� ----------------------- ' ` ------------- -------------------- ------- ---=----- --- ` -----------------•-- --------- ------------------------ _. ! t r .....--------`-------------------------------------------•------------------------------- ---` -------------------------------------------------------`------------------------------------------------------------------------------------•-------------------------•----•----------- -------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, nd ru s and regulations of the San Joaquin Local' Health District. 5 [Si `necl 9 )--� ••---- - •:•---�"-;--_--- --- ------- -'-:- " '=- ------ --•-- - ----- ---- -- - ---- -- --(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 w- APPLICATION ACCEPTED BY_------- ----- ------ ----- ---------------------------------------------- ---------- DATE-----X - ------------•---- rQREVIEWED BY----------------------------------------- -- -------- - -- - - `----• ----- -•-- - --------•------. DATE----- -----...- ---•-------------------------------- BUILDING PERMIT ISSUED ------------ - - DATE Alterations and/or recommendations:-------- --------------------------------------------------------------•----------------------------•--------------------------••--------...------------------- --------------------•-------------------------------------- ------------------------------- --•--•-----------------------------------•--------------------•----------------------------._.-...-.------- �. -------------------------------------------------------------------------------------------------------- --- -----------------------------------------•-----------•--------------------------- -----••-•--------- ----- -------------------•--------------------------•--•-----------M-------`-------- - FINAL INSPECTION BY:----- - ------------- --- ------------------------ Date----- . .. - -------------------------- ----------- V 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.