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i APPLICATION FOR SANITATION PERMIT Permit No. /1-0.3ss (Complete in Duplicate) Date Issued --------_--�___- Application is ereby ma_ o the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. k11V_1_X_1 JOB ADDRESS AND LOC TION "t J "= ;, Cx - - .--------' `` '��-S=q��`�' Owner's Name --------- `' = � � - 'f'i{4& C� ----------------------------------------- Phone------------- --------------------- Addressj"- '- - ----------------------------------------------------- ------- -- Contractor's Name--------------------------------------------- _-- _------------------------------------ Phone----------------------------------- Installation will"serve: Residence'©) Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---f---- Number of bedrooms 7-k Number of baths -__ Lot size -------7_ `___ -____ _J__` __________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam);d Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Ye No ❑ New ConstrTlction. Yes ❑ No" PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic �Ta k: Distance from nearest well------------ Distance from foundation--------------------Material________,________._-_-_-_-_________-_____-.--_-- No. of com artments____________________ _ Size______.._._-_.-,_ - -_Liquid depth------------- __-___-Capacity Disposal Field: Distance from nearest well____—•i__�._i___Distance from foundatiofn_____ A_ -___.Distance to nearest lot knee__--__._-.- Number of lines------------- LO- ____ r � ------=--�-------Length of each line-------- '� -, it--Width of trench-----�'-�-��---�------------- Type - - '� Type of filter material--_-_...6Q7 1__-__Depth of filter material___.______j_ Total length___________________________i:__f Seepage Pit: Distance to nearest well---------------------- from foundation-------_-----------Distance to nearest lot line----------------- 11 Number of pits----------------------Lining material------------------------Size: Diameter------------------------Depth---------------------------------- Cesspool, Distance from nearest well------------------Distance from foundation-----------Zn-__-.Lining material---------.---------.__---------_---_-. ❑ Size: Diameter-------------------- --- -------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------_--------------------------------------Distance from nearest building------------------------------,__._:,;�_ ❑ Distance to nearest lot line ---- ---------------------------------------•=-------------------------- .-----�------------------------------°----------- ` Remodeling and repairing {describe) ------------- ------�-----------------3----.----= ----------------------------------------------------------------------- " " r , Y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules/and regulations of the San Joaquin Local Health District. (Signed}- - �.� ''%_. -_C _. ----- ( / ) {{ ----------------------------------------------�---- -------- - -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 APPLICATION ACCEPTED BY-------------------- -`i - !►~' ----=-------------------- DATE-------- �� y .. REVIEWEDBY--------------------------------------=---------------------------=------- ---------------------------- --------------= DATE-------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------- DATE--------------------------------------------------- Alterations and/or recommendations--------- ------------ ------- -n--�--------�- ---------- ,---:----------- ---------------- ------- --- , --L--------------•------------------ --------------------------------------- f. _ K: -- - -------- --- - � y s � �Q ' ((JJ 11 -------------------- �./ F1NAL INSPECTION BY Date •- ------- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak'Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P.CO.