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APPLICATION FOR SANITATION PERMIT Permit No. --- -- __-_ (Complete in Duplicate) Date Issued -��/y��1 Sf .YA lira ion made to the San Joaquin Lo al Health District for a permit to construct and install the work herein described. This application is made in compliance with Count Ordinance No. 549. JOB ADDRESS AND OCATION....... Owner's Name--------- ! '•---- ---------- - - -- - ------------------------------------- Phone---------------------------- « Address------------------- - - l `*r ------&---' .... .--------------------------------------------------------------------....------------------------ G Contractor's Name.-- v ------------------------ Phone -l� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer` Court ❑ Motel ❑ Other ❑ Number of living units: _,[.-__-,Number of bedrooms___ Number of baths _ Lot size _---------------- Water Supply: Pubiic system ❑ Community system ❑ PrivateX Depth to Water Table�Sft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Njf Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yesx No ❑ FNA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) j Septic Ta k: Distance from nearest well100--------Distance,from foundation---M----------Materiai--- __-_r.v .____ ___________________ I No, of compartments----- ----------------Size 6"- 5 --------Liquid depth____l-- ---------Capacity_/-� _p___._. �w Disposal Field: Distance from nearest weil_1lW_____.._Distance from foundation----�A-_______Distance to nearest lot line---��_-___. ©/ Number of lines__-----CR___________________ Length of each -----Width of trench __----..___________ Type of filter material_�r��__ 95 __Depth of filter material_f8s-------------Total ---______________________ Seepage P' . Distance to nearest-�w•�ell_��-0_ ___----Distan om f undation___-_Za_-___.Distant e to nearest lot lineJ__ Number of pits-----s�-------_.--Lining material_ _._Size: Diameter_- 3--------------Dept'n__.,—? -----------.------ � Cesspool: Distance from nearest well-----------------Distance from foundation--------------.____.fining material-_______________--___________________- ❑ Size: Diameter-----------------------:------------Depth----------------------------------------------------Liquid Capacity---------------------------- gals. \`' Privy: Distance from nearest well.--------------------------------------------_----Distance from nearest building----.--__---_-____________________-_.___. - ❑ Distance to nearest lot line-- ----------------------------------------------------------- ------------ --------------------------------- ----------------------- � ----- �- 4- ---------- Remodeling and/or repairing (describe]:__. ^�'�� t �'3 ------- .---------- •---------- -- ------ --------- •--------------•---------- -------------------------------------------- ----------------------------------------------------- -- _. - ------ -------------------------------------------------------------------------------------------------------------------•----------- ------- ---- -- ---- --- --- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws, and rulestand regulations of the San Joaquin Local Health District. • 1 (Signed) '--- ` -"-- Owner and/or Contractor) By:---------------------------------- - ---------- ------- / --------------------------(rifle) -/--------------------------------------------- (Plot plan, showing size of lot, location of system in relat' to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY K ------------------------------------------------------------------- DATE REVIEWED BY------------------------------S ---------------------- --------------------------------------------- DATE- -------------- - ------------------------------------- BUILDING PERMIT ISSUED..-•---------------------------------------- - ----------------------------- DATE----- ------------ - ------------------------- Ir Alterations and/or recommendations: ----------- ---- ------ --- -.,-----• --------------- ----- -� rS _ -------------------------------------- - ------------------------------------ _.__iE y --T ""----n + __ - ------------------- ------ --------------------- ---;---------- G f I -------------- ------------------------------ •----:.------------------------------------------------------------------ FINAL INSPECTION BY:.----- a ------------------•- ------------- Date_ 1---LT__!^ai� 7 -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT J 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revisea 7.57 FRCO.