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APPLICATION FOR SANITATION PERMIT Permit No. .161.:-I_ (Complete in Duplicate) 3 Date Issued 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION -.---'-.----------- .• a� -- -- --- -- -- - ---------------------------- ---------- ------------------------------- Owner's Name------------- ..... ----- "__ - Phon ... Address----------Jr--_.3,0_Q_------� � > y Contractor's Name------- - -------------------•------------------------------------------------ -------•----------. Phone----------------------------------- Installation will serve: Residence (� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --/--_ Number of bedrooms ___-_ Number of baths ____/_ Lot size ____ Q_, _L.Q..Z)____________________________ Water Supply: Public system ❑ Community system A Private ❑ Depth to Water Table X0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [X Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 9 New Construction: YesX No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Tank: Distance from nearest well_�QQQ_T Distance from found _/0 t7,rial___� __------------ Septic _ 4 No. of compartments.___'j�__________.Size.�s�_�-x_,c.��'__:___Liquid depth____ _�- '______Capacity____ __ Disposal Field: Distance from nearest well_/0-0-0-*istance from foundation___-_�/Z------Distance to nearest lot I' 'v Number of lines-- ------- Length of each line--------- Width of trench--_A__ .__��___________ _a �. N Type of filter material__Y—T _ _Depth of filter material___...-___---_-_Total length____---7 __________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation___-•_--__-_--__---.Distance to nearest lot line----------------- R 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):------------------------------------------------------------------------------------------------•-------------------------------------_--------------- -----•----------------------------------------------•-----------------------------•----------------------------------------------------------------------------------------------------- ---• ----------• --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------=-------•--•------------------------------•---------------- ------ -----------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County CU ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. O (Signed) ---------------- --- AAZ =`+� -------------------------------------------------------------------------------------(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.--------------------------------------- REVIEWEDBY----------------------------------------------------------------- ----------------------------------------------------- DATE------. -------------------------------------- -7 BUILDING PERMIT ISSUED. 5-2- --------------------- DATEAlterations and/or recommendations___________________-__ _ ._-_____ __ ----------- --------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------•----------- ---------------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- ------ - - - ------------------------------------------------------------- ------ -------------------------- ----------------------------------------------------------------------------------------------------- FINAL INSPECTION BY------------------ -------• Date---------6----- S ------- ----q--------------------------------- 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.RCO.