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APPLICATION FOR SANITATION PERMIT Permit No. ._..1.E(D tt y...�.... _ (I7omple4 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 County Ord4nce No. 549. 7 _ Jp.-,f)y JOB ADDRESS AND LOCAT ON--------------------- _ -�. __�-____--4r4 fYL1J----l-.d c ---------- Owner's Name-------- ' -Cz_��2 Phone = �/`yZAQ ------------------------------------ ------------ Address------------------------_--- .......---------4--I9d_✓ -e�- ---------------------••---- ------------------•--------------•---------- •---•-------•---- ----- Contractor's Name - -}---C/ .— ----- Phone-----------_---------------- -- ----------------------------------------------------- - Installation will serve: Residence Apartment House ❑ Commercial F] Trailer Court [3 Motel ❑ Other ❑y Number of living units: :'__ __._ Number of bedrooms 3_._ Number of baths,, Lot size ------- ------- Water gWater Supply: Public system E] Community system ElPrivate a Depth to Water Table ./¢ft. � Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,,'Clay Loam ❑ Clay E❑ Adobe ❑' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YesR 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 Tank: Distance from nearest well____!Distance=from foundation--------1D----.Mata ial___ C!�J �r�°! - L No, of compartments--------�------------Size_______ _ _�X.. Liquid dept -------------Capacity._.___.t?Q._T------_ X11 Disp_os�l Field: Distance from nearest well_.___- -Distance from foundation______Ad......Distance to nearest1ot line______•.'r'�r._ rte(\ Number of lines-------„3------------------------Length of each line__________ 40 --____--.Width of french--------- 6_ ___ ------�----uJ � - -�. Type of filter material .. _-._ Depth of filter material_______A?---------Total length___.____--_____- 4_'__________ -� Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-...----------------------------- 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------------------------------------------------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------- •--------------------------------- -----------------------------------------------------------------------------------•--------------------- ----------------------------------------------- ------ -------------------------------------------------------•----------•-----•--------------•-------------------•--------------------------------------------------•--------------------------------------------------------------- ----------- -------------------------------------------------------------------------------------------------------------------------------------------------------}-------------------------------------------------------- 1 hereby certify that I have prepared 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. ($igned --------- . --------------------------------------------•-------------------(Owner and/or ContractorlV%. 51-----------------------------------------------------------------------------------------------------------------------------------(Title)----------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ---- - - ------------ DATE------- -------------------------------------------- DATE- REVIEWED BY` v-T-- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ Alterationsand/or recommendations----------- -------------------------------------------------------------------------------------••----•--------------••----------•---------------------------- ------------------------- -------------------------------------------------- - ------ ---------------------------------------------------------------•-------------------------------------------------------...------------ - ---------------------------------------------------------------------------------------•------------•---------•-------• ---•-------------------------•---•-•--------------.---•------------------------------------------- -----•----------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- ----------------- ---------------- ------------------- --- ---------- ----------- -- q f1 FINAL INSPECTION BY:..------ k--------------------------- Date------- y. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-92M Revised 8-'59 F.P.Co.