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APPLICATION FOR SANITATION PERMIT Permit No. 10.... ..�� (Complete in Duplicate) /2-/ 3 Date Issued --------------1--.___ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T(((h��i��`s application is emade in compliance with County Ordinance No. 549. 2J -_ d(ep r} O ADDRESS AV LOCATION - ;4------ ---- --------- �j Owner's Name- - - p.'� ----------- �----- - ---- - -------------------------------- ------- Address .....��` l ---------- ------- ----- -----------------------------•-------------------------------- ------------------------------ Contractor's Name----eV to '----- ---------------------------------------------------------------- ----------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: )___ Number of bedrooms -ZI—_ Number of baths 7,t. Lot size ------ ---------_________________________ Water Supply: Public system ❑ Community system ❑ Private W Depth to Water Table 0__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 4' Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No M New Construction: Yesg No ❑ 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- -d_+-Dista e from foundation./�-_.---__. Materia!_ ---- ----- __________________________ J�°�-i No. of compartments___�_-.-__________--Size_V5�",3_-_-_-----Liquid depth_---'�-----------------Capacity-. _--___ - Disposal Field: Distance from nearest well4a--------Distance from foundation-1 ------.Distance to nearest lot line_J .......... Number of lines----a_2------- -------------- Length of each line-____70_'_--_-__-__----.Width of trench-__-A-/__°�------------------ Type Q. T e of filter materia _ 1J yp � � __Depth of filter material length-�-��-'--------------------------- � r� Seepage Pit: Distance to nearest well----- ----------------Distance from foundation--------------------Distance to nearest lot line__--------------_ Gy ❑ Number of pits------------------ Lining material-----------------------Size: Diameter------.----------------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-- ---------------------------- --------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- f --------------------------------------------------------------------------------------------------------•---------------------------------------------------------------•----------------------------------------------- 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] -- - -------------------------------------------------------------- ----------------{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_ - -------------- REVIEWEDBY------------------------------------- ---------------------------------------------------------------------------------------- DATE------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------ ------------------------------------ Alterations and/or recommendations:------------------ --------------------------------------•----------------------------------------•---------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------•----------- ----------------------------------------------------------------------------------------•- -----------------------•------------------------------------------ -----------------------•---------------------------------------------------------- --------------------------------- ----------•-q------------------------------------------------------------- FINAL INSPECTI Y:_ Date f .- 1+ ----------------------------------------•---- 1J OAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California / Manteca, California Tracy, California ES-9-2M . Revisers 1.57 EP,CO.