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po APPLICATION FOR SANITATION PERMIT Permit No. .-d..l_-A-4.1..../ (Complete Com lete in Dulicate) This Permit Expires 1 Year From Date Issued -- t��" vn Date Issued J............... d-S F Rpplication 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 LOCATION____-_ r- �l�`�LaC.t� fU___ ..../_ .1__ -• __ _______ '- Owner's Name-------. =_ _ ------------- Phone.-j�--S.57_3 ( ------------------- -I Address------------_------------ '�'_Z_? . ----------------- ----------•---_... Contractor's Name----- I -- a ---------------------------------------------••---------------------- Phone,!" -7-- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court X Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size --- �_ ___, '_____________________ Water Supply: Public system x Community system E] Private [-] Depth to Water Table -------- ft. Character of soil to a depth of3>>feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No K 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 Tank: Distance from nearest well_________________Distance from foundation--------------------Material_--___-_-_----___-_-__.__--________-_.___-______- ❑ No. of compartments----------------- --s-.�- Seize--------------------------------Liquid depth-------------------------Capacity----------------------- Disposal F' Id: Distance from nearest well----*'_'Y-istance from foundation___6Z 1----Distance to nearest lot line__.1-_ _`. All Number of lines_______________ ___________ Length of each line-------- _1___-_-_.Width of trench__-._�- ---------------------- ---- ----____.___-_______ Type of filter material--- Seepage of filter material----/''!______.Total length-----,/' 'b_:�_____________________ Seepage Pit: Distance to nearest well---- Distance fram fo nd ---ation - Distance to nearest lot line_.,,<.....__._ (� ❑ Number of pits------�----------Lining material_ /1L- .Size: Diameter___ ' _.___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-----------_----------------------..-____. ❑ Distance to nearest lot line--------------------------------------------- ----------------------•-------------------•-------•--------------------•-------------- ------ Remodeling and/or repairing (describe):------------------------____.............................................................:---------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- ------------------------------------------ --------------------------------------------•----------------- ------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work wW be done in accordance with San Joaquin County ordinances, State laws, and rules regulations of the San Joaquin Local Health District. (Signed)------------------------------•_----- --�� ------ -----------------------------------------------------------__------------------(Owner and/or Contractor) - ---------- By:---------------------------------------•-------------- ------------------------------------------'----------------------------------(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_.__7_R P_l _ -- ------------------------------------•---------------------------------------__ DATE--------,1----�-Q-�-�-�----------------------- REVIEWED BY---------------------------------------------------------------- ---------------------------------------------------=------ DATE----------------- ----------- ------------------------ - BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- 15 : `::::::::::::::::::::::::: -----Alterations and/or re ommendati ns•_____ :: : -- -- :: ::::::: : ------------------------------ )r7 ::::: :: > ------------------••- -------•----------------------------------------------- ---- -------------•------------ ---------•------ ----------- -------- i-•------------------------------•----•---•------_-_--_--••-------------------•-------------------------------•--- E FINAL INSPECTI ---- -- --- --- --- - - Date----- -f_.`___ _ `. ----7------------------------------------ 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.