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i APPLICATION FOR SANITATION PERMIT Permit No. ....__�.7.._____7. n� ' (Complete in Duplicate) Date Issued ---3A//(ev This Permit Expires 1 Year From 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 LOCATION------- .f;�7.�------ - --- . .. -------------------------------------------------- -•-------------------------------- Owner's Name 0----___--- ---" ------------- ---------------------- AddreAddress ss---------------------------------- -- - —---- --------------------------------------------------------------------------------------------•----- Contractor's Name_____________ ___ ---- ------------------------------------••-------------------- - ------ Phone-N-0-4 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 Number of living units: __/_ Number of bedrooms _a_. Number of baths I--- Lot size .__� ______________________________ Water Supply: Public system ❑ Community system ❑ P'rivateDepth to Water Tableys7ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [B`�Harclpan ❑ Previous Application Made: Yes ElNo New Construction c Yes ❑ No �HA/VA: Yes ❑ No E:1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer.is available within 200 feet.) Septic >n k: Distance from nearest well __ Distance tom foundation_-_�-P_,____.Mate�af_._�1__G_�_� - --_l._�__'__�____--------- ____ [� No. of compartments........._Q�_-----------Size_�_la__ X3-6---- .--- Liquid depth------VA-----------Capacity_S®D_ _ Disposal ieid: Distance from nearest well_51 Distance from foundation_.__3.4_______-Distance to nearest lot line________________ Number of lines-----------/---------------------Length of each line____..�.__0----------------Width of trench...�3__-___-.__�______________ Type of filter material._ `___/QE�Depth of filter material-._.__�_ ____-___Total length________._____, 4Q________________ i Seepage Pit: Distance to nearest well_-_/j0P_______Distance from foundation___-_710 a to nearest lot line__--_„J_______ W] Number of pits-_____1------------Lining material____ � L�_.Size: Diameter_______-33__--____Depth___._- ��~_______-_ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material........-__-_____________________- ❑ Size: Diameter--------------------------------------Depth_---------------------------------------------------Liquid Capacity--------------------------gals. Privy: Distance from nearest well_________________ ______________________________Distance from nearest building___--__-_ ❑ Distance to nearest lot line------------------------------------------------------------------ ---------•--------------------------------------------------------------- Remodeling and/or repairing (describe):-------------------- ----------- -------------•------------------------------------------•-----------------------------•-------------------------- --------------------------------------------------------------------------------------------- •---------------------------------------------------------•------------------------------------- ------------------------------ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. (Signed)---------- r --�---- -------- --------------- - -------------------------------------------------------------. .(Owner and/or Contractor) By:----------------------------------------------- l (Title)-- 4?4&--------------- (Plot plan, showing size of lot, location of system in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -- - ------------- ----------------------------- DATE------ --------- REVIEWEDBY------------------------------- -------- --- -- ------------------------- ----------------------------------------------- DATE-------------------------------------------- •----------- - BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------- --------------_------ Alterations ----- --- Alterationsand/or recommendations:---------------------- --- ------- --- ------I---------------------------------------------------------------------------------------------------------------- ------------------- -------------------------------•-------------------- ---------------------------------- ----------------------------------------------------------------------------------------------------------------- ---------- ----------------------------------------------------- ------------------------------------•-- ------•----------------------------------------------------------------•--•---------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------•----- -----------------------r---------------------------------------------- FINAL INSPECTION BY: --------- ------------------- Date _ 02/_: �P ��----------------------------------- 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 8-'59 F.P-CO.