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APPLICATION FOR SANITATION PERMIT Permit No. _l ---1_L6 (Complete in Duplicate) 5� c Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the ork herein described. This application is made in compliance with County Ordin No4��Oz 549 � , el ,zr .��JOB ADDRESS AND LOCATION_ __ _------ -- - ----------- ----------- --------------------------------------------cam Owner's Name--------------- ----- ----- ------------ ----- - ------------ -------- -- � Phone ---------- Address--------- Contractor's Name---- '�" *� v "'-C .: ' Phone_ . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____/_ Number of bedrooms ---/_ Number of baths I-__ Lot size ______.___.�7._ �_ ----------- __,__ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table _______ ft. �+ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if pulplic sewer is available within 200 feet.) Septic Distance from nearest well----_Orv-Distance from founc(ation---'ZZ-------Materia _ _____ No. of compartments_____' `_ Liquid de th__.: — _ Ca cit Disposal Distance from nearest well _- __._Distanfrom foundation----V.0_____......Distance to nearest lot line--- Number of lines-----'______________ ___--- --Length of each line__-__-'-Q__�_._ �f_.Width of trench__-c�_�!!_______- _ Type of filter material..314& --- _.Depth of filter material-_____-l.�__�__Total length-------------------- ....�. Seepage N Distance to neare t well_..___ 9-_____Distanc from foundation_....__Z�.__.Distance to nearest lot line____-___ Number of pits__._--_--__ -____Lining material AC.�______Size: Diameter___33 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--------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, laws, and rules and regu tions of the San Joaquin Local Health District. D7C( Q ________-_ r-Contractor (Signed) -1----t% - ---------!rel�atii = ) e By:----------------------------------------------------------------------- -------- -------.(Title)---------------------------------------------- ---------------- (Plot plan, showing size of lot, location of system in wells, buildings, , can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------- ------------------------------------------------------------------ DATE----------------- ------ P-------------- REVIEWEDBY-------------------------------------------------------- - ------------------------------------------------------------------- DATE------------------- ` -- ---------- BUILDINGPERMIT ISSUED--------------------- ---------------------------------------------------------------------- DATE--------- ----- ------------------------------ Alteraf ions and/or recommendations:- ------ --------------------------------------------------------------------------- --------------------------------------------- -- ---- ---------------------------------- ---- .----.... ------------------------------------------------------------------------------------------------------------------------ 7r ------k--_--__--_- -- -------------------------------------------- FINAL INSPECTION BY:------- ___ Date---------- '� SAN JOAQUIN LOCALALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P.CO.