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APPLICATION FOR SANITATION PERMIT Permit No. _'t? -6.1 (Complete in Duplicate) �/ Date Issued --- T4- 12V App'iication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicofion is made in compliance with Cou y Ordinance No. 549. JOB ADDRESS LOCATI !_ Owner's Name..__. />✓.' '---- --//••------------- --------------------- ----------- - ------------------- ------------------- Address ----.-----.----•- - Phone._.. Address....-�,.............. 4�r. ---------------- -•----------- •------------------- Phone_±.........'. Contractor's Name- --- ....... -....... ------.:..--------------- ._..---------------------- - Installation will serve: Residence [> Apartment House ❑ Commercial ❑ Trailer Court ❑ Mo el ❑ Other [I Number of living units: -I....._ Number of bedrooms ..k- Number baths _t..--- Lot size Water Supply: Public system ❑ Community system E] Private Depth to Water Table _-.-__-_ ft. Character of soil to a depth of 3 feet: Sand Gravel E]Sandy Loam E]Clay Loam E]Clay ❑ Adobe 0/'Hrdpan [7Previous Application Made: Yes ❑ No [vNew Construction: Yes 52�'No ❑ FHA/VA: Yes ❑ No F1 TYPE OF INSTALLATION AND SPECIFICATIONS: ;' f (No septic tank or cesspool permitted if.public sewer s available within 200 feet. Septic T nk: D;slance from nearest well.4510'.r "Dista ce fry, fo}}�wdation- 1-0......__..Mater a , No. of compartments -----_-..a.Y-_q_ALiquid de�ptth----J'..i, ....... ...... Capacity--..(�Q Q. DisField: Dis=ance from nearest well -5' Distance from foundation. /Q�Distance to nearest lot lin pos7 Number of iines___.._----- ---------------- Length of each line.�C)_-'6Z:—y5 %-Width of trench-.- . Type of filter maferih_"4�D epth of filter material.----_� .__ -� �...... ..Total length.. .................. Seepage P;f: Distance to nearest well_ _..________________Distance from foundation -------------------- Distance to nearest lot iins ................. ❑ Number of pits_ ...... _-........ .._ Lining material ------- _ ---.Size: Diameter,.-.. ..... ... . ... Depth. ...... ...................... _ Cesspool: Distance from nearest well ----------------- from foundation -------------- ..__Lining material ..................................... ❑ Size: Diameter - ----- - ---------------- ------------Depth--------- - -------•--------- _..... Liquid Capacity... .... __...... ------- _gals, Privy: Distance from nearest well---- ..................•-._--_-----___..... _ ..Distance from nearest building--------- --------------------- ---- El 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 ordinances, Sfate laws, and rules ssrand 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 fo wells, buildings, etc-, can be placed on reverse side).' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED--------- DATE"".. REVIEWED BYts -------- , . ---- --------------------------------------------------- .... DATE -- - BUILDING PERMIT ISSUED ----------- ----------- ------------- --....---•-----•---_--____ .------.....-•-..........---••- DATE--- .._._.......... iP Alterations and/or recommendations:-----...._ ...- --------------•--_--;....................................... _.......... - ___ --------------•- ....------------------------ -•---------------- ___ _I—------------- .............................................. ------------ ........................ ................ .... ................. ...................... ---.--....... .------ -------------- --- •----------------- --..................................... .--• ----•------ ......------.............. -•-•--------• --••------------------- -- --......-.----------------•..-.................. . .--....................................... ---------•-•••.......... .......... _... ------------- ........... ................ ......... ........ -.--•--- ------.._....-- ............... ---•-----------•-----... ................ -.-..------------------ FINAL INSPECTION -----_ Qate..�.r�. ...._..-._....._..... 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 , Revisoa 1.57 F.P.CO.