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F' APPLICATION FOR SANITATION PERMIT Permit No. ------_----- (Complete s.--___(Complete in Duplicate)` Date Issued . _ rs`�Y I Application is hereby made to the San Joaquin Local Health District for a permit to cos ttru t and i all the work herein described. This, application is made in compliance with County Ordinance No. 549. JOB ADDRESS A CAT N. - - ---- Owner's --Owners Name I - ------------R-- hone ---- �. Address V------------------------------------------------------------------------------------------------------------------ Contractor's Name--•---- _ ---------------------------------------------•-------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units: l.._ Number of bedrooms%l___fNumber of baths ..__f_ Lot size .- -Lr? _X_L?_:c�_ --------------_---------- _____ Water Supply: Public system `[eCommuni+y system ❑ Priv ate ❑ Depth to Water Table _41`I t. _ Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sand Loam Clay Loam Cla' . Adobe Y Y ❑ Y ❑ [?'-/Hardpan ❑ Previous Application Made: Yes �o ❑ New Construction: Yes �o ❑ FHA/VA: Yes ❑ No [>� TYPE OF INSTALLATION AND SPECIFICATIONS: it (No septic tank}or'cesspool permitted if pI' sewer is available within 200 feet.} Septic Tank: Distance from nearest well_ -__-- y_t_uista�nc,�� from foundation__/e------------MaI trial___ ____________6 _________ _ ___._____. N'. of 'compartments __ _ _-_-.__Size__1_;4pC'7-----.___Liquid depth__.____ __________Capacity__. - t Dispo I Field: Distance from nearest well__. rDistan Ie from foundatio �� - :Distance to nearest !otne____________ ____ Number of lines___-___-3__ _ __________ __Length" of each line_______` _ ____._.Width of trench.___ Ty' l /f .r } ______________------- p _____ I Type of filter material____ _ epthllof filter material"__-:X-________Tota) length_____- ____________________._ Number of its Linin matsf ia� � l - I ry . ____ e from foundation--------------------Distance to nearest lot line____El _________. -------Size: Diameter----------------- Depth----- - ------------------------------- Cesspool: ----------- ------ t Seepage Pit: Distance to nearest well___.:_.-�____ Distant Cesspool: Distance from nearest well---"- ----Distances from foundation____________.____.Lining materiaL___________________________________- ❑ Size: Diameter �D'eptly -----------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___________________________ ________________Distance from nearest building------------------------------------------ ❑ Distance to nearesf la# line--------------------------- ----------------------•------------------- Remodehing and/or repairing (describe)= --------------------------------------------------------•--'-------------------------=-------------------------- -------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun+y ordinances, State laws, and rules and regulation of th San Joaquin Local Health District. (Signed}....' ------ ------------------------------------ - -- ------------------------------ ------------------------------------------------------(Owner and/ r Contract Y. By- - (Title) ----------------------------- ----•-- ------------------------ (Plot plan, showing size of Iot,'loca+ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY j APPLICATION ACCEPTED BY-------------- -------- ---------------- ------------------------ DATE------- -------------- REVIEWEDB�----------------- ;-- -------- -- ------------------------------------- --- 'DATE---------! -------------------------------------------- BUILDING PERMIT ISSUED DATE!-•---------------=------ --- -- DATE -:--- ------ -----------------•------------------ - } Alterations and/or recommendations:-------------------------------------------------- --------•-------------------------------------------------------------------------------------------------- --•--------•--'------------------------- ----------------------------------- ----•----- 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 ES-9-2M Revised 1.57 F.P.CO.