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APPLICATION FOR SANITATION PERMIT Permit No. ..{.1.2-A (Complete'-in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the Son Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AN ATION-- P- ---------- -------------- Owner's Name--------------- � Phone,, �- 4 r.2. Address - ----- - 7 -•--------------------•-------- - Contractor's Name ----- ----------- Phone...... -------•----•----------- Installation will served Residence IX Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units Number of bedrooms _Number of baths __,Z_- Lot size ------ _- Water Supply: Public system ❑ C&i4iunity,system,❑ Private ❑ Depth to Water Table 3__- £t. Character of soil to a depth of)'feet: Sand Gravel ❑ Sandy Loam R Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes [�. No { 'New Construction:, Yes ❑ NoE FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204rfeet.) Septic Tank: Distance from nearest well---/_A?__Distance from foundation _._!Q____._.Material---------- No. of compartments------------- --------Size---------------r ='_ . quid"depth------------t Capacity p Disposal Field: Distance from nearest well--- Distance from !oundation.____9__4)_._..Distance to nearest lot line____-_--_ Number of fines_________________ Length of each line-___� _- 9P-;-AP------ of trench--_.____-_'�_-------_---- i �� ' ` i Type of filter material---_ __Depth of filter)material----.__��_.-------_Total length___.___._____ 00_C9- ------------ Seepage Pit: Distance to nearest well--------- --_-_Distance fromfoundation__________________.Distance to nearest lot line-_____-._________ ❑ Number of pits----------------------Lining material----------_--- --_----Size: Diameter-----------------------Depth--------- ----------------------- Cesspool: ----____-__.__ -Cesspool: Distance from nearest well-_____________ __Distance from foundation--------_-----------Lining material------------------------------------- El ______.._.__--_-.___.____--____ __❑ Size: Diameter----------------------- Depth% Li uid Capacity_--------------------------gals. Privy: well � Distance from nearest well-_________________ ______________________--___._Distance from nearest building--------------------------------------- Distance to nearest lot line------------------------ - ------------------------ Remodeling and/or repairing (describe):__ _ �L__ �j .- , .�„ . - -�- - -- ----------------------- -- ------------ - - --------------------------------------------------- '1 ------------ 7 - --------------- - ------------------------ 1 hereby certify that I have prepared this application and that the work will be done in actor ce with San Joaquin County I ordinances State laws, and'rulgs and regulations of the San Joaquin Local Health District. (Signed)- �,� '+S'`e�t -------------------------- -(Owner and/or Contractor) ' - ---------•------------------------------------------------------------------------------------------------ --- ----------- Title ------------------ - -------------- {Plot p n, showing size of lot, location of system in relation to wells, ings, etc., can be placed on reverse side). FOR SPAR MENT USE ONLY APPLICATION ACCEPTED BY_______________ _____ ____ • -- --------------------------------------- DATE- -1 s REVIEWED BY DATE -------------- -------------- BUILDING PERMIT ISSUED---------------- - -- --------- DATE---------------------= Alterations and/or recommendations---------- ----- - ,----------- ��.��_rv__ -• --'------ rt ____ ---------------------------------- --------------------- ------------------------------------------------ FINAL INSPECTION BY:.. ' -----�---`-- 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 ES-9-2M Revised 8-'59 FT.Co.