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r APPLICATION FOR SANITATION PERMITPermit (Complete in Duplicate) Date lssued .F'/ r(l 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 Ordinanc No. 549, JOB ADDRESS AND LOCATION------!�` �" -��" ---------- Owner's Name------- -��----1.�' - --u----------- ---------------------------------- ------------- ------------- -- - --- Phone_---------•-------------------- ` �� - --------------------------------- -----------•------- ----------------- Address-------------- ► �' ------------- -- - Contractor's Name----- ------------------------------------------ Phone... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _______ Number of bedrooms _______ Number of baths -------- Lot size -----------_________________________________________________ Water Supply: Public system ❑ pCommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted,if public sewer is available within 200 feet.) Septic Tan Distance from nearest well.-----Distance from foundation___ �. . .....Material : ` `----------- �-TNo. of compartments-----I--------------------Size i -------Liquid depth---4..T'.._. -----C nearest ----------------- Disposal Distance from nearest well_________________Distarye romio nndation_.___________._____-Distance #o neo I I nE ❑ Number of fines------------------------ ----------Length of each line------------------------------Width of trench------------------------------------ Type ----------- ..-------------------Type of filter material------------------------- of filter material----.______ss_,,^ -..Total length------------------------------------------ - lsrd ------Distance to nearest lot line-------- .----- {� Se page Pit: Distance to nearest wefgp.Q�__----__Distance from foundation___ Number of pits--- if---------------Lining material Size: Diameter_ _�'!� --._---Depth-- _&____________________ G ' 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------------- --------------- ---------- 0 ----- --❑ Distance to nearest ]of line------------------------------ ----------------------------------------------------------------- I R mode4ing and/or repairing (describer---- - -----------•- ---- -------------•---- Re --- -- - --- ------------------- - - -- - --------- ------ ----- --------- ------------------------------------------------------------------------------•--------------------------------------------•---------------- ---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counf y ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------ ------- d�T ._�se._F.... 'asr Contractor] B . ------------------------------ (Title)( }- (Plot plan, showing size of lot, location of system in relation to ells, building etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY �- xlm APPLICATION ACCEPTED BY DATE - -- - 4- --- - REVIEWEDBY---------------------------- --- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED-------- ----------- _ DATE--------------•-------------------------------------------- Alterations and/or recommendations:------------- -------- ------------------ ----------------------------------------------------------------------------------------.--------- ------------------------------------------------ -- - -------------------------------- 4 �A ---------------- --------- FINAL INSPECTION BY: ------ Date_ - ------ --- ------- SAN JOAQUIN LOCAL HEALTH DISTR CT 130 South American Street 300 West Oak Strod 132 Sycamore Street 814 north "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 r.P.CO,