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APPLICATION FOR SANITATION PERMIT Permit No. .l..Z. o.. ..._ (Complete in Duplicate)' -w -- -This Permit Expires 1 Year From Date issued -Date Issued O_ _ _____________ 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. JOB ADDRESS AND LOCATION---------------------( -2, -------;-- Owner's Name------------------ �----------7 -• - -f - ---------------- --------------------------- ------- Phone-- • ------------------------------ Address------------------ --�--�---------=- --------=-=-'--- ------ - =--------------------�----------- ---------._...------------ Contractor's Name - C i-� -------- ----------•---------------------------------------•---------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial, ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units.,,-,"'.- / 1 Number of bedrooms _______ Number of baths ____ __ Lot size ____________________ Water Supply: Public systemK Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth c4 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Ye�_N No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ ;r TYPE OF INSTALLATION.AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) `1 Septic Tank: Distance from nearest well---X�-----Distance from foundation__._./d _.____ Material____ �Qf---- No. of compartments----------- --:-------Size-- --- - ------ Liquid depth---------��----------Capacity-_'_ _ -'---- R DVal Field: Distance from nearest well.----57 ...Distance from foundation--- 4:21__'.-----Distance to nearest lot line--- 5 --'__:___ }� Number of lines----------1_______ _ Length of each line___._____-)�"�____---_.Width of trench---------�_�.__________-.___ . Type of filter material------------ - .--Depth of filter material--------- length----------�d_-__-__________------- Seepage Pit: Distance to nearest well.__�_ - ._Distance from foundation_--_-_� ��_.Distance to nearest lot•line_ -__._ _rul \ Number of pits--------/------- _Lining matenalJ�Size: Diameter._-31 `/ �1pepth-------- ______----_,-.- Cesspool: Distance from nearest well-----------------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 Remodela d/or repairi fdescribe):--- /I -_• � '".) --- - f _________ ___________________________ / I hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta aws and rules4rtions of the n Joaquin Local Health District. (Signed} ------ ---- - ----------------------------------------- -------------------------------------(Owner and/or Contractor) By' le --------------------=---------- --------------------------------------------- ----- (Title) (Plot plan, showing size of lot, Iota+ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ------------ DATE------ APPLICATION ACCEPTED BY F �_�__"2s Cf-- 1� REVIEWEDBY-------------------------------- -------------•------------------------------------------------------------------------------ DATE---•------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------=--- DATE-------------------------- -Alterations and/or recommend:_- ------ �,r�------------- - _ ------------------------------------------------------------ ----------------------------------------------------------------------------------- ------------------------ ------------------------- ----- FINAL INSPECTION BY:..... i-- ---, .� nW Date------------ --- v�d SAN JOAQUIN LOCAL HEALTH DISTRICT 00 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 F.P.Co. ~