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l ( -- APPLICATION FOR SANITATION PERMIT Permit No./ . ... .... (Complete in Duplicate) to I Date Issued This Permit Expires 1 Year From Date Issued e,4. Application is hereby made to the San Joaquin Loc l)-Iealth 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 LO TIO ---��g�y Owner's Name--11�6,- -__-_-- -- !:! "' --- !_46 Phone.................................... Address !� . --------------- ---- - ---- ---------------------- --- --- Contractor's Name. --�-----------------------------------------r-----------------•- - Phone----------------•----•••--...--•-•- -------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units: ____/__ Number'of bedrooms _____ Number of baths _ ___ Lot size ____________________________________________________________ ``JJ � Water Supply: Public system (Community system El Private El Depth to Water Table Z- __ ft. Character of soil to a depth of 3 feet: -Sand ❑ gavel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No E��New Construction: Yes ❑ No Z�- FHA/VA: Yes ❑ No P9- 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__----------------------Size...........--------------------Liquid depth--------------------------Capacity---------------------_ 1 Disposal Field: Distance from nearest wellnsd ,__„Distance from foundation..._Q._._........Distance to nearest lot line. . �.... Number of lines...---------- ----- Len th of each line___�'•Q'-_lp_ _____-Width of trench____ _ __ �' Length of filter material.__`4_C'(___-__Depth of filter material-----/8"___`�-------Total length........,?.0.�______________________ Seepage Pit: Distance to nearest well_____________________Distance from fougdation/O -...Distance to nearest lot line__. -4�_.�. lij - Number of pits______:Iu__._.____-Lining material_____ 4_4__-Size: Diameter----3.3----------Depth___A+p_-_•2�i`_.__ , 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 will be done in accordance with San Joaquin County ordinances, State laws, and ruleXonof ons of the San Joaquin Local Health District. (Signed)----------------------------- -------- ----- -----------------------------------------------------------------------------------(Owner and/or Contractor) By:------------------------ ---------- ------------------------------------------------------------------(Title)-----•----------- --------------------- -------------- (Plot plan, showing size o o , loe in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------�!&-*_--------------------------------------------------------------------- DATE----- --------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE.------------......------.................................. BUILDING PERMIT ISSUED--------------------------------------------------------------------------- --...._.....----------- DATE---------------------------------------------------------- Alterations and/or recommendations:_._ ______ - --------- --------------------------- ----- -- -- -- ------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------_--- -------------------------------------------------------------------------------------------------------------------------------,.------------------------.------------------------------- FINAL INSPECTION BY:, ' {_ -r._!lL _ Date------- _ _fc'�_ -- -------------------------- ------------------ 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.