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APPLICATION FOR SANITATION PERMIT Permit No. "a ,. )(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 application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIO _l------ -© �G cL�------ ---------------------•----------------------••--------- ------------- w, Owner's Name--------------------- -- �- 7 ------------ �I _._W. -- - ------------------------------- --- Phone- Address----------_ honeAddress----------_ ------------7�'-�1-----ss_._-C _-D!_ z�.Psu-------- ----------•--------------•-------.-.--•-------------.-.---- Contractor's Name--------- _.. ` Phone Installation will serve: Residence E& Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 8 O Number of living uriits:._�____ Number of bedrooms 1v--- i---- Lot size ------ -- -- --�--- __ Number of baths __ ---•••-------- ----------•-------- P Water Supply: -Public system ES. Community system ❑ Private ❑ Depth to Water Table -------- ft. {I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe a Hardpan ❑ Previous'Application••Made: Yes ❑ (No % New Construction: Yes No ❑. FHA/VA: Yes ElNo E] i ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pertritfed if public sewer is available within 200 feet.) i t I �� -•-- .Material. -l�4 '_C� -- ------ Septic Tank: Distance from nearest well___ Q-..____Distance from,fou tion____.__ _ .. No. of compartments--------_�`�------ ----Size-+� ------------------------Liquid depth---�------ ---------CapautY----- -- •-`-- -�� 1 t %, - Disposal Field: Distance from nearesf well_.—._____.Distance from foundation__-._�_,_i._____Distance to nearest lot line_____ __________ r�n j� Number of lines________ _ -—-__- -_ Length of each line, ?-1_ t�!`F�� Width of trench.._�f__�____ ________________ �.` of filter materiaL___1�- DepthSAL---____ of filter mater ______..___Total length------- Type __ ________________ Seepage Pit: Distance to nearest well_____________________Distance from foundation-------------------.Distance to nearest lot line----------------- Vl ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------- ----Depth-.-.-. -------------------------- Cesspool: Distance from nearest well_-------------Distance from foundation....................Lining material-_._________--.---__.______________ ❑ Size: Diameter--------------------------------------Depth------------------------------- ------------------Liquid Capacity-----------------------------gals. `. y Privy: Distance from nearest well--------------------------------------------_-Distance from nearest building-------------------------------------- -- ❑ Distance to nearest lot I' line------------------------ ---------- ---- ----- ----------------•--------------------------------------------------- ------------------------ ---------------- --------------------------------------••--------------•----------------- RemodeGng and/or repairing (describe): ---------- ---- ----------- ---------------------------------------------- ::__ ___ : � _ -- ------------------------- _- ______ ___ ___--_ - _ _l _____ ___ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) t � -----------------------------------------------(Owner and/or Contractor) j Tale (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 l DATE----------------- �- APPLICATION ACCEPTED BY �--•------------- -- ---------- �---------- ------------------------- -- REVIEWEDBY----------------------- •------------------ , --------------------------------------------.- DATE Z ' BUILDINGPERMIT ISSUED------------------- ----------- -------------- ---------------------------------------------- ------ DATE------------------------------------------------------------- Alterations and/or recommendations:--------------------- - ----------------------------------•-•-•--------------_------•-------••----------------------------- -------•---------•------- ••---•--------------------------------------------------------------------------------------------------------------------•------ ----------------- ----------------------------------------------------------- FINAL INSPECTION BY-------- -------- - ---------------------- --------------------- Date.... ------- ..... ------------------- ------ -------------- - 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 F$.9-2M Revised 0-'59 F.P.CO.