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APPLICATION FOR SANITATION PERMIT Permit No. _ _...4qA -_ . Cpl. (Complete in Duplicate) Date Issued 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 applicationris made-in-compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------ X ��,�'••••-- �� lcx �r Owner's Name.---- ------/ *----- r`;_. _ ./� -------------------- ---------------.-------------------"-- - -- ------ � ( Address---= �--�-------•--------L= --:��€� ........ •--�..��r--��1��-------4� Contractor's Name------------- ---- 5__x, _ > -T Phone o Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court 1E] Motel Other ❑ Number of living units: - ------ Number of bedrooms Number of baths _1____ Lot size - Water Supply: Public system ❑- Community system ❑ Private/ Depth to Water Table &/q ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy 'Loam ❑ Clay Loam ❑ Ciay ❑ Adobe Hardpan C] Previous Application Made: Yes E] No ❑ New Construction: Yes E] No E] FHA/VA: Yes ❑ No ❑ . TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Wetie r Distance from nearest well---------'-------Distance from foundation--------------------Material______.______...___-_--.____.-_______.______--__. -� No. of compartments-------------"------------Size---------------------------- ---Liquid depth----------- -- Capacity - ne--------------------------- ---Width of trench.--------------•-------- -------- i...— Disposa�, d� Numabee of lines well--------------- Distance of foundation--------------------Distance to nearest lot line_____-__-________ {R Type of filter material-------------------------Depth of filter material----------------------- length---------------------.------------- :----- Seepsa Pit: ------------ Number of nearest ell___149 I ` material Distance_{ - '.� _,Size: Dia'� Distance to nearest lot line_._ I-----..__-- p 9meter- --------.Depth C 'spool: Distance from nearest well------------------Distance from foundation------------.-------Lining material--------------------------:_-:------- ------------------------------Li Liquid Capacity gals.;: '• ❑ Size: Diameter--------------------------------------Depth_ - ---------------.- q p tY----- --------------------.9 Privy: Distance from nearest well--------------------------------------- ----------Distance from nearest building------------------------------------------ m, , ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (de -- - ---- -—'---------� ------------------- -------•-•--------------- :---- . - --- -------------- - - --- ----------------------- -------- " -------------------•---------------- -------------------------------------------------------------------------------------------------- - -- ---- Ihereby certify that I have prepared this applicatio that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules andfmgulafions of a Sa Joaquin Local Health District. (Signed)----------------------------------------- -F--- G,�/a�� _ �� (Owner and/or Contractor) Title ` -��' �J-_ B ---- --------------- (Title) [Plot plan, showing size of lot, location of systeA in relation 4 wells, buildings, c., can be plated on reverse side). FOR DEPARTMENT USE ONLY e r APPLICATION ACCEPTIrD BY DATE----------- -- a---- --------- REVIEWED BY----------------------------------------------- -- J DATE U BUILDINGPERMIT ISSUED-------------------------- L '----------- -------------------------------------- DATE---------------- ------------------------------------------- Alterations and/or recomm ndations---------------- ------------------------------------r '---------•------------------------------•-------•----------------------------------------------- ----- .._ _---------------------------------------------------------------y - -------------------------- .................. ------------- --------------- .. FINAL INSPECTION BY__________________ _____ Date----- �"I 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-92M Revlsed 6-'59 F.P.Co. l