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APPLICATION FOR SANITATION PERMIT Permit No. l._ __.q (Complete in Duplicate) Date Issued 20 1�— 1LF1i0 --d-2.— 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 Cor o ty Ordinance No. 549. JOB ADDRESS AN LO 10 Owner's Name =r " --------------------- Phone-- � ----------•--- Address '�� -- Contractor's Name---------------- --- - -----------------------------------------------I .-. Phone---------------------------------- Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _____ Number of bedrooms ----I-- Number of baths ____l___ Lot size --- %11_-------/1 %11_42,4---- ---------------- Water Supply: Public system ❑ Community system [I Private k Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand V Gravel ElSandy Loam ElClay Loam ElClay Adobe E] Hardpan El Previous Application Made: Yes ❑ No U� New Construction: Yes No E] FHA/VA: Yes ❑ No [ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--- .------Distant from foundation__ _____.Mate a _ ___.___-_ - --- ----------- -------------- No. of compartments--- _v__._.Li uid depth p -- - -�Size-- -••�-�/? �q i= ---------------CapacitY....?eL�---- --- 3 _____Distance to nearest lot 1'ne_ -. Disposal Field: Distance from nearest well_ __�_____.D'rstance from foundati _ .. - Number of lines----------1___-._ ___-_A--Length of each line------q_L_)__ Width of trench. ___-�,,_�_____.;___-____-- Type of filter Depth of filter material----_ _ Total length___-__ / 4 Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______..____--.._ ❑ Number of pits---- Lining material-----------------------Size: Diameter------------------------Dept h---------------.----------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material------------------------.------_---_- 171 Size: Diameter--------------------------------------De th---------------------------- _______________________Liquid Capacity Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-----.-_______________________--_-_____. ❑ Distance to nearest lot line-------- ------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ----------------------------------------------------•-----------------------------------------•------------------- ------------------------------------------------ I hereby cer if that I have prepared this application and that the work will be done in accordance with San Joaquin County r: ordinances, Stat lry s n regulations of the San Joaquin Local Health District. i (Signed)-- --------------------------------------------------------------------------------------(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 APPLICATIONACCEPTED BY----------------------- ---------------------------------------------------------------------- DATE-------------------------------------- -------- --zz,, REVIEWED BY----------------------------------------------------------- - - DATE:------------{ �t1 I BUILDING PERMIT ISSUED--------------------------------------- DATE---------------------------------------------------------- Alterations ---- -------------- - -- -------------- Alterations and/or recommendations:-------------------- --- ---------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------------•------------------.-.---------- --------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------- ----------------------•---------------------------------- ----------------------------------------- --------I--------------------- ---------------------------------------------------------------------------------------- -----------------------••-- -•-------- ---------------------------------- ------- ---- -- --•-------- ------- --•-------------------------------------------------------------------------------------------------------- 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.