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1 1 w APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued .._.. }�___�p 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. 49. JOB ADDRESS A CAT N-•-- � e"A -------------- - AC= � f ----------•---Owner's Name----- --- 4---Ie(----------- _ --------- --------------- Phone---------------- I Address---••-......----- ------------ ------------------------------------------------------------------------ ---- --- -- -- - - ------------------------------------------------------ PhoneContractor's Name-------------------------------------- I Installation will serve: Residence ®---A-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Number of bedrooms -:3_ Number of aths _ _ Lot size ______ ___________________________________________ t Water Supply: Publics stem Community system Private De th to Water Table __ ft. PP Y' Y ❑ Y Y ❑ P Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [5r--gardpan ❑ P Previous Application Made: Yes ❑ No W---New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (N septic tank or cesspool permitted if public sewer is available within 200 feet.) e i k: Distance from nearest well_________________Distance from foundation------------.------Materiai______________________T_�``_ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------�`- Ile / r Distance from nearest y+efl___�--------Distance from foundation___ �_______.Qistance to nearest lot line._ �/ Number of lines----------_f--___.______ g f Len th of each line------ of trench______._. y_______________ Type of filter maferial_1 - -_ --Depth of filter material-______,"J_ __.Total length_____________�,�-_-__-___.___..__,- Seepage Pit: Distance to nearest well----------------------Distance from foundation----.----------.___Distance to nearest lot line----------------- ❑ s - Number of pit ----------------------Lining material Diameter--._------------_ ----Depth--------------------------------- Asspool: Distance from nearest well---------------_-Distance from foundation-------------------.Lining material_-_________-__-_-.----____________ ❑ Size: Diameter--------------------------- ----------Depth---------------------------------------------------Liquid Capacity----------------------------gals. t i Privy: Distance from nearest well___------- --------------------------------------Distance from nearest builcling------------------------------------------ ElDisfance to nearest lot line--------_--------- ----------------- ------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------•-------------------------=-•.r--------•----•-•------------------------------------------ -------- -----------I-------------------------------------------------------------- ` ----------------------------------------- -----------------------------------------------------------------•-•-•---•--------------------------------------------------I---------------------------------------------------- 11 -----------------------------------------------------------------------------------------------------------•-----------------------------------------------------------------------------------------------------------` I hereb(fa tify t t I have prepared this application and that the work will be done in accordance with San Joaquin County " ordinances, I and rules and regu tions of the San Joaquin Local Health District. (Signed) - 4 �- --- -- --`-1--- ----- ----Y------- ------ - weer and/or Contractor] B (Title)------ -- ........................... (Plot plan, showing size of lot, location of system in relation to welfs, buil gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----"Tt-_K�D-------------- ---------------------------------------------------------- DATE------- .= � '-- ----------------- REVIEWEDBY------------------------- ----- ----------- -------------------------------------------------------------------------------- DATE-------- ---•----------- ----------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------- --------------------- --- -------------------------•---------------•------------------------------------------------ ------------ ----------------- _ -- ------ Date--.---/-.r �� ; FINAL INSP - -- - - -- -- - - -- -- - -----------• - --------------------- SAN - - ----- 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 Revised 0-'59 F.P.Co.