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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ' This Permit Ex ires 1 Year From Date Issued 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 applicaFio_n is.ma a in,compliaiice with County Ordinance No. 549. JOB=ADDRESS 'AND L CATION. --� _____�c __ar________________ -, Owner's Name------ --- A -------------- �. ----------------- Contractor's Name________ _ �s -- ---Wm ? ---Z4 - ----------- Phone_._( .�-/.Q-,nstallation will serve: Residence ❑ Apouse ❑ Commercial Trailer Court ❑ Motel Number of livingunits: _ ❑ Other ❑ Q__.Number of bedrooms _p_ Number of baths -------- Lot size _____..__ Water Supply: Public s stem �©"a" X �-� x Y� y ❑ Community system ❑ Private ❑ Depth toWater Table -__ ft. Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam E] Clay L � Previous Application Made: Yes ' Yoam � Clay ❑ Adobe El Hardpan ❑ ❑'1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes 1] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: pis}ante from nearest well_________________Dista ce fr'om foundation _-Material______!.______.-_-"-_----- - "_- ❑ No. of compartmems--------------------------Size-----F ----------- --Liquidodepth------- `--Capacity--------- --- +-------- Disposal Field. Distance from nearest well--------------- -Distance,from.foundation_____________ ____.Distance to nearest lot line------------- A Number of lines_'___________________________�-__Length of each lin------------------------------: " :1/Vidth of french-_____________ --------------- Type of filter material_____ r"----Depth of filter material _ -iTotal length__________________________ -—-Distance to nearest welL_____________�____ ``• __Distance from oundation_____-ti__-----, istance to nearest lot line___,(:_ - -_-� dumber of pits :'.,_--��-. '-_`Lining material_ __ __.Size: Diameter__-x----5---Depth ❑ . ' Li uid De th-__._Cesspool: Distance from nearest well___ rom " - o ________--___.___.Lining material--- ------_ ------------Size: Diameter--------------- - -- ---Dept h------------ ---------------- Privy; _______ -__PrivY; Distance from nearest iwell` GCapacity---------------------------9a1� from nearest building--------------------------------- ------------------------- Distance to nearest lot line f..__---__".-__-_--___----------------------------__i_ i •--- --- -- ------- ----.---- Remodeling and/or 'repairing (describe):__ --"--__ � � �� ' f ------------ - . f ------------- •--------•---` ______________•-____ ____.______________________J___-_ _________________ _ C r. I hereby certify that I have prepared this application arid,that +he 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)----•---------------- ---------- ------------------------------------------------ ----------------- --- Ow ," � xner and/ori Contractor) BY: ---, ----------- -- --- - --- -- --- -, - -- -- ------ - -- --- - -- - - _ - ---------------------- -- --- - - (Plot plan,,showing siie of lot, Iota+ion of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY_ ---------- ---------------------------------------- • REVIEWED BY DATE l ------------------------ ------------------------------------------------------- ATE------------- ---=.. BUILDING PERMIT ISSUED---------------- ----•----------------•---------------- �•`-L', DATE _._--____.___.__...--------•-----------_ - -------- -------------------------------- Alterations and/or recommendations:. --------- - ----------------------------------- ------ M ----- -----------------•------------------------ ww -------------- ------------------------------------------------------------ - --------------------- FINAL INSPECTION BY:.0 ------ ------- - .Date---- -------- - ll SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street. 132 Sycamore Scree! 9i4 North "C" Street Stockton, California Lodi, California Manteca, California i } Tracy, California FS-9-2M Revised 8-'59 F.P.Co. k