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APPLICATION FOR SANITATION PERMIT Permit No. ..�- 3 7.7 (Complete in Duplicate) /� This Permit Expires 1 Year From Date Issued Date Issued ______ 7 GD. 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 compliancet!b C;oun Or ' ace No. 549 JOB ADDRESS AND LOCATION... p -----•- ------ � 1�/--------------- Owner's Name T --- ---� .� . ,... Phone - •---- ............. / Contractor's Name .�JrG/rS q -�O�l„Z f?�✓(.,R Phonevrs., 10 ,1 Installation will serve: Residence Apartment House F1Commercials Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._.____. Number of bedrooms -------- Number of baths ________ Lot size -------f---fc----�.- -------........."'""_._.... Water Supply: Public system ❑ Community 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: tt Gl (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep is Tank: Distance from nearest well._-"-------Distance from foundation----,A........Material_____---ew!S.�'-------------- � No. of compartments-.--__- --_-___-_--Size_ 1._ __:__-Liquid dept__.�Z► ApIpip Disposal Field: Distance from nearest well-�-•_.-.-Distance from foundation...4.0..._---Distance to nearest lot line.- Number ineNumber of lines......../-----------------------Length of each line.....4Q__.--- ----------Width of trench---G----�y_-------._________--_ Type of filter material_________________________Depth of filter material---------- ----------Total length.......................................... Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- F-1 Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Dept h_-_-__-_-.-._.-_-----___-_._----- 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--------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------.......----•-------------•--------•-----•-•-------------------------------------------------•----------•------------------------------•---- ------ --------------------------------•-----------------.......................................--•------•-------------------------------------------•-------------------------•------------------•------------------------------- --------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------- ------ - I hereby certify hat I have prepRinrelation d that the work will be done in accordance with San Joaquin County ordinances, State s, and es a reguJoaquin Local Health District. (Signed)---- ---- ---r' - ------ --- ----- Owner d/o jContractor) BY: ------ ----------------(Title) - (Plot plan, showing size of lot, location of so wells, buil s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------------------------------------------ DATE_.LZ-_'-----'G--------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------------•----......................................... ----------------- --------------------- ----------------•----------------------------------------------------------•-------------------------------------------------------------------------------------------•-•-•-•------ ------------•--------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------..---------------------- --------------------------------------•---------------•------------------------------------------------------------------------------------------------------------------------------------------•-------------------------- --------------------------------- ------- ---------------------------- ------ FINAL INSPECTION BY:,i� �'t-------------------------------- Date_...1/1 -_-� -/sQ 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 F.P.Co.