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APPLICATION FOR SANITATION PERMIT Permit No....j�-3-_ �t 1 (Complete in Duplicate) Date Issued ---- _/L_�lP_a-_ This Permit Expires 1 Year From Date Issued 'Application is hereb� 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 �th ounty Ordinance o. 49. JOB ADDRESS, AND% CATION / --------••---- Owner's Name ---------- 't..-_-_--• _ ---------------- Phones /--�_ Address-----------•-------- 4------ ---- ----------- - ----------- ------------------ Contractor% Name ------------------- -• ---------------------------------------------- Phone ----------------------------------- Installation will serve' Residence Apartment House ❑ Commercial ❑ Traile Court 01to ❑ Ot er ❑ f Number of living units: __/-__ Number of bedrooms _G_Number of baths f___ Lot size ---- ,----- �--- _-..-- ----------- Water Supply: Public system C< Community system El Private `❑ Depth to Water Table _ __ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,k Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ NoAj�_ FhiA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS-. (No septic tank or cesspool permitted if public sealer is available within 200 feet.) r Septic Tank: Distance from nearest well --- �____IDistanc from fours fion______/Q_-___.Mat ,,I 'aa ___________ ____ No. of compartments_-.-_fSize___d__Liquid-depf}i_______ __________________ Capacity ---- fj'' Disposal Field: Distance from nearest well _._.Distance from foundatloop,,/..U________Distance to nearest lot Ii a-- -- Number of. lines__ / :_,f ____ __ ________ ____ Length of each line______ ._.Width of trench___ Y ------------------- Type of filter material-- epth of filter material____.1a---------- otal length_____ ____________________ Seepage Pit: Distance to nearest well. y____________ -------- Distance from foundation ------- ..___....___.Distance to nearest lot line _______________. ❑ Number of pits ---------------------- Lining material -----------------------Size: Diameter ----------------------- Depth --------------------------------- Cesspool: Distance from nearest well ----------------- Distance from foundation....................Lining material ---- ..-____---_-_________._________- '0 f. Size: Diameter-------------------------------------- Depth ----------------------------- ----------------------Liquid Capacity ---------------------------- gals. Privy: -Distance from nearest well -------------------------------------- .-------- ._Distance from nearest building _____-____.----________________.__.____._. ❑ Distance to nearest lot line-- -- ----------------- ---------------------- Remod ing an or rep -ring (des e);-- - -- -- -- -- - ------------------------- ------ --------- ----- -------------•-------------- --- -- - ---------------J------------------------------------------------l,-------------------------------------- /----------------- ------ ------------------------------- ereby certify that I h e prepared this application and that the work will be done in accordance with San Joaquin County ord' nces, State laws, and rules and regul tions of the San Joaquin Local Health District. - (Sign ed '- - Owner and/or Contractor {Title). (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMMT USE: ONLY APPLICATION ACCEPTED BY ------------------- ----- ) - - ----- ------ ------ D �E---------- - ----------------------- REVIEWED BY ----------------------------------- --------- ------------- ------ - g- ---•--. - ATE- — --- BUILDINGPERMIT ISSUED ----------------------------- ------------------- ------------ DATE-------- --- ------ - - ------------------------------------ Alterations and/or recommendations--- ---------------------------- - - ----- ---------------------------------------------------------------------------------------------------------- ---�---------- - ----•- ---------------------•----------------------------------- --------------- ----------------------------------- _ __ ____:: _ _:-___________________-�:__-- ---___----------------------------------------------- - - FINAL INSPECTION BY:.----�' we ---------- Date .... 111 --- --?-A ----- 0 JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES -9-2M Revised 8-'59 F.P.Co. 300 West Oak Street 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California