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APPLICATION FOR SANITATION PERMIT Permit No. ...1......7.....0 (Complete in Duplicate) Date Issued -----1---------6G-- This Permit Expires 1 Year From 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 complianceywi h.County,Ordin nce No. 549. _ 44�✓ (�7 JOBADDRESS AND LOCATI N---------- ----- ------ - ------- ----- -- ------------------ -------------------------------------•----------------------------------------------- Owner's Name------- = ------ - = -- -----" -------------------- Phone...-.------------------------------ Address------------------------------ --- ----- ---- - ----------- - .......... 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 ------------_---------______________________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 5_4 ft. I � � Character of soil to a depth of 3 feet: Sand [—] Gravel E] Sandy Loam El Clay Loam ❑ Clay El Adobe [Hardpan ❑ 4 Previous Application Made: Yes No ❑ New Construction: Yes [&, No ❑ FHA/VA: Yes ❑ No ❑ P TYPE OF INSTALLATION AND SPECIFICATIONS: l (N*p� T ptic tank or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well-----------------Distance from foundation__-__________-_____.Material-.-----------------___ --_ --_. __No. of compartments----------------- :-------------Size•---•---------------------------Liquid/depth--------------------------Capacity-•---------•------Distance from nearest�w``ell//d12�/ _Distance from foundation_._/.4_______-Distance to nearest lot lire-__Number of lines------:--4P------------ -- Length of each line---- -. ------��_---Width of french---- ��.--------------------- Type -_----------------- N Type of filter material_'''- __Depth of filter materia!____--/9_________Total length---------------------7_•5 ------- Seepage Pit: Distance to nearest well----------------------Distance from foundation___--_-_-____--___.Distance to nearest lot line__-____-________ ❑ Number of pits-----------------------Lining material---------- Size: Diameter-----------------------Depth--_---_--_-________-___________ Cesspool: Disfance'from nearest well-----------------Distance from foundation-- -----------------Lining material-__-____----________-____________--__. ❑ Size: Diameter---------------------------- -------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------- --------_Distance from nearest ❑ buiding----------------------_-__--------_---_ rest lotline Distance to near -------------- ----------------------------- i - = ,P ----------- Remodeling and/or repairing describe) 141? . - ,.. �._.. ----------------------------------------—--------- ------------ ------------------ --------------------------- ------•--------------------------------------------------- # 9. I hereby certify that I'have prepared this application and that the work will,be done in accordance with.San Joaquin County ordinances, laws, and r es.and.;regulafions of the San Joaquin Local Health District. - (Signed)----••---- - -------- -------------------= ------------------ ---Won rier and/or Contractor) --- a -�-'�°�-'-- ---- ---------------- (Plot plan, showing size of lot, location of system in relation to Is, uildings, etc., can be placed reverse side). 1 FOR DEPA ENT USE ONLY APPLICATION ACCEPTED BY---------------------- =----- - ---------- --------------------- -------------- -------------------"--------------".. .I:_ DATE- ---------- -� REVIEWEDBY------------------------------------------------ --- . ------------------------------------------- DATE------(0-"---(0--4--------------------------------------- BUILDING PERMIT ISSUED--------------------------- ------------------------------------------------------------------- DATE--------------------- ; Alterations and/or recommendations:------------- --- ------------ ------------------------------------•---------------------------------------•----------------------------------•-•----------- i c -------------------------------------------------------------------- --------------------- -------------------------- -_--_------------•-----------_-----------------------•--------------•------ FINAL INSPECTION BY:---------- ��i?'_G,.. --------------------- Date...CQ---1 ------- -------------------•---------- SAN JOAQUIN LOCAL HEALTH DISTRICT j 130 South American Street Sao West Oak Streot 132 Sycamore Street 814 North "C" Street 11 Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M Revised 8-'59 F.P.Co.