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1 { 'n APPLICATION FOR SANITATION PERMIT Permit No. .,�/. �� (Complete in Duplicate) � b 3 Date Issued This Permit Expires 1 Year From Date Issued ued _____________ V` n 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 eNNo. 549. JOB ADDRESS AND LOCATION---------e� �- , L � w--'-""--------------------------------------------------------------------------------- �- ---- Owner's Name f ------ Phone-- Address------------------------4�___ ax---- --L----d------------- -- - - --------------•------------------------------------------------------------•------------------------------------... Contractors Name------------------��.t�'------------ a d_-------- ----..----------------------------------------------------------------- Phone./101V._S Z�e Installation will serve: Residence tj--K�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _��nity r of bedrooms Number of baths I______ Lot size _._.. ___«k-.1--2y -------------------Water Supply: Public system system 0 Private ❑ Depth to Water Table _��__ . ft. Character of soil to a depth of 3 feet: Sand ❑ el ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpa Previous Application Made: Yes ❑ No New Construction: Yes ❑ No �A/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k--r Distance from nearest well_________________Distance from foundation....................Material____-______:____-_____-_:__________-_-__--______- No. of compartments-----------------------_-Size--------------------------_---Liquid depth--------------------------Capacity----------------------- Disposal Fiel : d Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_________________ Number of lines___________________________________Length of each line------------------------------Width of trench__--_________,__________-__________ Type of filter material______________ ___-_-_ -_-Deepth of filter material__-_____.____--______--Total length.......................................... Seepage P' Distance to nearest well---.�_" _distance from foundation_/,________.Distance to nearest lot line:,. __ ____ Number of pits------- ______-____Lining material--- -Size: Diameter 3.i---------------Depth_-�S__ __._______._ 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------------------------------------------ Distanceto nearest lot line------------------------------------------------------------------------------ ---------------------------- ❑ _/-/ Remodeling and/or repairing (describe: ------ � °�-�f�f � - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I 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 lations of the San Joaquin Local �Health District. (Signed) u ------- --------(---'---------------------- (Owner an /or Contractor) By:-------------------------------- ------. — -- ----------------------(Title)_._ (Plot plan, showing size ocat n of system in relation to wells, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------- iR�--------------------------- ------------------------------------------- DATE------/9--"------------------------------------------ REVIEWEDBY----------------------------------------- --- ------------------------ DATE--------------------•-•----------------.................... BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------ ------ DATE------------_--------------- ---------------------------- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------•--------------------------------- ------------------------------------------- ------ ---------------------------------------------------------------------------------------------------.----------------------------------------------------- ---------------------- `P!T �� pT H- �''r K = rtt -° IX -/ s, ------------------ -------- ---- - ------ 15xFINAL INSPECTI B • — Date-- / -rl ....-- ----------------------------------- 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.