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APPLICATION FOR SANITATION PERMIT Permit No. _.._!_..LSI. ../._. (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. /W/j O 0 � a JOB ADDRESS AND LOCATION__ ---- ------------------- - Owner's Name----� ------ ------------ '`' i`- Ph'ot�e Address----••-- .._.l.{. -------------_------- - --- ------------•------------------------ -/_ - -- ---------------------------------------------------- Contractor's Name_ -----------------------------------•----•-------------------- -------------------••----------..._-•--------------..---- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----- Number of bedrooms __ ._ Number of baths - __. Lot size --------------- -------------------------------------------- Water Supply: Public system ® Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel p Sandy Loam ❑ Clay Loam j-M] Clay ❑ Adobe ❑ HardpanA Previous Application Made: Yes ❑ No TR New Construction: Yes"A No ❑ FHA/VA: Yes ❑ No ❑ d TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material_______------------_-.--.----..------__-_._---_. .011 No. of compartments-------------------------Size------- ------------------------Liquid depth--------------------------Capacity---------------------• - Di sal 'eld: Distance from nearest well---�-. .___-Distance from foundation.--1-tfl----------Distance to nearest lot line_ _.._.__. Number of lines-._./_---------------------r Length of each line-_-_____d.42----------------Width of trench-------100;-_--_----------_--_ Type of filter materia '�'(�-------De th of filter material.._.. �0 Total len th.-.. ° Seepage Pit: Distance to nearest well_ . _ ____._-Distanc m un tion _-_/_p___----.Distance to nearest lot line---`- fr ---------Number of pits.-.-I---------------Lining materi� t _Sze: Diameter___ _�____._-_-_Depth... _'57_1__.__._.__.___... Cesspool: Distance from nearest weil-----------------Distance from foundation--------------------Lining material-..._--.--._______._-.---------.-. ❑ Size. Diameter---------------------- ---------------Depth------------------------------------ ---------------Liquid Capacity- -------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----- -----..----.----__-___--__.--_-. ❑ Distance to nearest lot line--------------------------r------ ----------------------------------------------------------------------------------------------------------- Remodelingand/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, Stat laws, nd rules and regulations of the San Joaquin Local Health District. I (Signed)-- : . - -,-�-� ------�------------------------------------- Owner and/or Contractor) By:---------- ---- ---- ------ ------------------------------------------------ ----:(Title]----- (Plot plan, showing si a of lot, ocation of system in relation to wells, buildings, etc., can be place on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -------------------------------------------------------- __A4 7 G. -- - -- - DATE--�--- -•------------------------------------- - - - REVIEWEDBY----------------------------------------------------------------------------------- ------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------------------------------------------------------------••---------•--•-------------------------------------------------------- ---------- •------------- ---------------- -----------------------•-------------------------•---------------------...---------_----•---•-------•-------•-•--------------------- FINAL INSPECTION BY:- A04L-�_ 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 FS-9-2M Revised 8-'59 F.P.Co.