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1�4 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) , /__��_ _ This Permit Expires 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 application is made in compliance with County4*nance No. 549. l tr7-130—z5 (5`125 JOB ADDRESS AND LOCATIO - �-�--------------- Owner's Name---- z------ ------- --------------------------------------------- Phone-----------------------------.------ Address - ---------------------------------------------------------------- --------------- Contractor's ------- -- - - Contractor's Name ° -. ----- --- Phone ----------------•-------------------•---- - Installation will serve: Residence Ej`Apartment House ❑ Commercial ❑ Trailer-court rM'-�,Motel ❑ Other ❑ Number of living units: __/._ Number of bedrooms-_9:_Number of baths Loft size ------------------------------ k � f Water Supply: Public system �ot m,' unity system ❑ Private ❑ Depth to Water Table XA ft. 1 Character of soil to a depth of 3 feet:? Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan 0 Previous Application Made: Y.A ❑ Np,PD New Construction: Yes ❑ No [ FHA/VA: Yes 25-"--No ❑ a TYPE OF INSTALLATION ANCF SPECIFICATIONS: (No.,septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic Tank: Distance from nearest well--------------_-Distance from foundation__________________Material No. of comparf en,ts------- Size Liquid depth Capacity--... f �. Disposal Field: Distance from nearest well----- from foundationF--�p_�____._ Vidt Distance to nearest lot line___��__--•_ Number of lines._-•�'- ---------- ------>=eniathiof each-line > �Nidth of trench--- f------------------ Type of filter ma4rial_/'_A 7 epth of filter material___ __.________-Total length--------1�&..______________________ Seepage Pit- Distance to nearest�`well------`"'--------Distance fr fou dation___ �__r_._.Distance to nearest lot line----------------- U ___'' _�._ _ ', i I�umber of pits....___1_.__._____.Lining matersaL_ ��_ .Size: Diameter- -----------Depth_.___ ___ i Cesspool: Distance from nearest well,______:_.______Distance from foundation___._____.___..__-:Lin'sng material______________________________________ Q Size: Diameter. -------:t_/-------------- ----------------------------Liquid Capacity----------------------------gals. _ ---------Depth --------------------- � Privy: v` Distance fro nearest-well"_--'______-----_____-_.______________---- -Distance from nearest building_____.._____.--____.____________.._---._. I ❑ ' Distance;fo_rnoarest lot line-------------- -------------------------------------------•--------------------------•------------------------ --------------- i Remodeling and/or; repairing (describe)i _____________ _ _ _ �•'•' } -------------------------------- - ------------------------------ "4 ----------------------------------- -------•----------------------------------------------------------------------- �i c ------------------------:---=---------------- -------------------- --------- ------------ I hereby certify that 1have..p;epared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules`:and regulations of the San Joaquin Local Health District. 4' --_ �. ------------------------------- ------------------ (Signed (�r Contractor) } .---- ---•------------------- ---- - ---- �� (Title)_ ---------------- -------------------------------- -- ------ (Plot plan, showing size of lot, location of stem in relation to wells, buildings; etc., can be placed on reverse side). 1� FOR DEPARTMENT USE ONLY DATE APPLICATION ACCEPTED BY------- ---- -------------------------------------------- f - -� ' �'� � REVIEWED BY------------- -------=----------------------- -- =------- -----------------------------------------• -;----------------- DATE------------- --- - -------------------- BUILDINGPERMIT ISSUED------------------- -------------------------------------------------------i--------------- DATE------------------------------------------------------------ Alterations and/or recommendatio .... ...- --�-- - { �r « - to -' ---- -------- -- - - i C", Date. ---------- ------------ - --------------------------•---FINAL INSPECTION BY:.. _____________________ SAN JOAQUIN,LOCAL HEALTH DISTRICT 130 South American Street £ 300 West Oak Stree} * r�132 Sycamore S rest`% 814 North "C" Street Stoc7iton, California x Lodi, California Manteca, California Tracy, California ES-9-2M Revised 6-'59 f.P.co.