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A ?, APPLICATION FOR SANITATION PERMIT Permit No. ... (Complete 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 Ordinance No. 549. JOB ADDRESS AND LOC TION_ _ ................. Owner's Name----------- � .1 / Phone Address. ` e ;r ------------- �' - Contractor's Name ..... _� t= '�-- - - ------------------------------ Phone ez: Installation will serve: Residence A ippartment House ❑ Commercial ❑ Trailer Court ❑ *tel ❑ Other ❑ Number of living units: _/--_-- Number of bedrooms _Z_ Number of baths j.____ Lot size _ _, '___ , j '_______________________-• Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy\Loam ❑ Clay Loam ❑ Clay ❑ AdobeV Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes [-] No � FHA/VA: Yes F] No [I/TYPE OF INSTALLATION AND SPECI IF CATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) .teptic" an�- ; Distance from nearest well-----------------Distance from foundation--------------------Material----------------_ -.-.__-..__.____--------____. No. of compartments----------__ _______ ---Size-------------------------------Liquid depth_-__ ___._ _..-----------Capacity Dispoeld = Distance from nearest welL.."? -------Distance from foundationI Distance to nearest lot lin ........... �iw f 12;0Number of lines---------/----------------------Length of each line-------,/-- _.... ....Width of trench____,,, :/ _______________ [, Type of filter material_---------------------- of filter Material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line__.-_._-_-_-__--- ❑ Number of pits----------------------Lining, material--------------- ......Size: Diarneter---------------_--------Depth-___----._-_--__---_-__--__---• Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------- -____---_.__-..._-. ❑ Size: Diameter--------------------------- ----------Depth-------------------•----------------------- ------Liquid (;apacitY--------------------------gals. Privy: Distance from nearest well___----------------------------------------------Distance from nearest bit'17ding_-_-----_--__-_______-____--_-.---.-__--_. ❑ Distance to nearest lot line--------- ------------------------------------------'................-•---------- •---------------- Remodeling and/or repairing (describe):. r' - _------ •------ - ------------------------------------------------------------------------------------------ ---- ------ _� a ••-.r.- ----- _ - = z--------------- .•-•------------------•----------------------------- ----------------------- ------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certif that 1 have pre application and that the,work will be done in accordance with San Joaquin County ordinances, State w , an rales d regulati ns of the San Joaquin Local Health District. - _— %' (Signed) �`(� Owner and or Contractor _ z BY� ----------------1 r z G= --------(Title)----- =. --.� ---------- (Plot plan, showing size of lot, location of system in rel ion to wel)s, buildings ., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY_- _+__._ _ � _�.6 -------------- -------------------------------------------------- DATE-------------r------- 1------------------------ REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE---------------------------------------------------------- BUILDING PERMIT ISSUED-----------------•------------------------------------------------------------------------------------ DATE--.------. ----_------------------------------------------ Alterationsand/or recommendations----------------------------------------- -------------------------------------------------------------------------------------------------------------•------. --------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------•••-• ................................. ---------------------------------------------------------------------------------------------- -----__•----------------....------------------------•---------------------------------------------------------------- --------------------------------•-------- --------•------------------------------------------- ------------------------------------------------------------------------------- -----------------..............._------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ r FINAL INSPECTION BY:. r �- "' Date /= - -------� ------------- --- --------- 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.