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APPLICATION FOR SANITATION PERMIT Permit No. . _. ..... (Complete in Duplicate) / This Permit Ex fres 1 Year From Date Issued Date Issued ----- Application -_Application is hereby made to the'San Joaquin Local Health District for a permit to construct and install t ork. rein described. This application is made.in_compliance wi h County Ordinance No 549. JOB ADDRESS AND LOCATION -- ________- -_ a2" Owner's Name---_-_: p ___ Phone--. -------------- - Address-_.-----•--•----------• - ----------------- --- Contractor's Name - -- Installation will sere : Residence [kf Apartment House ❑ Commercial I ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units, 4----- Number of bedrooms \3--- Number of baths _ pi Lot size �* ------- Water Supply: Public system A Communit system Y Y ❑ Private ❑ Depth to Water Table _ - eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 4i Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes I–] IR New Construction: Yes ❑ NoA FHA/VA: Yes [] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest II_car ----Distance fr m fou, ation--1 V_---------- ----------------------- .Material No, of compartments ' 4 p .- Size =' _ �` Liqurd depth-----. Capacity_.J --[t Disposal Field: Distance from nearest w,11-4�_-. -Distance from foundati n___lk --------------Distance to nearest lot line-- '--_•___ Number of lines----__i7- ---- - -------- Length of each line-__--0i --.Width of tr ch._-136--" -_-__ Type of filter materia fj �j -- -- --fa- -Depth of filter material---lk_- ---------Total len th---._-- f �- 9 Seepage P;#: Distance to nearest w L___---_-------------Distance from foundation--...___----___.-_-.Distance to nearest lot line____----_---_.- ❑ Number of pits--!------------------Lining material----------------------.Size: Diameter------------_- 1 Depth ------------ Cesspool: Distance from nearest well-----------------Distance from foundaf;on... ---------------- material_---_--_..-___________- Size: Diameter est w l -------Depth------------------------------------------------------ ------------------------------------- ---------Liquid Capacity--------------------- ----gals. Priv Y= Distance from nearest well--- from nearest.buildin sg------------------------------------ ❑ Distance to nearest lot line_-.-___--------------------- ------------------------------------------ Remodeling and/or repairing (describe):---__--------------------- ----------- - - -------------------------------- ----- -------- -------------------------------------------------------------------------------------------------------------- -------------- hereb certify tha+ I have - ` Y Y prepared this application and that the work will be done in accordance with San Joaquin Coun+y ordinances, State laws,—and rules and regulations of the San Joaquin Local Health District. (Signed)------ C ----------- - - ----------------------------------------------------------- (Owner an Contract By: Y - '` �� _ ------------ ---- ------------------- (Plot (Title} _:. or Contractor) plan, showing size of lot,'location�tof system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ - ------ DATE_ -__- REVIEWED BY --- ------------------------------------ - DATE - ------------------------------=---------------------- BUILDING PERMIT ISSUED-----------------=----------- --- ------------------------------------------------------------------ -- - ----- ------ DATE------ --------------------- I Alterations and/or recommendations:------_---________________ -------------------------------------------- ------------------------------------ ----- --------------------------------•----------------------------- - --------------------I---------------------------------------------------- ------------------------------------ ff FINAL INSPECTION BY:. . 4 Date------ 4�s _"�l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "G" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.Cc. -