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APPLICATION FOR SANITATION PERMIT Permit No. ._.� (Complete in Duplicate) Date Issued _____t'_:�g ' This Permit Expires 1 Year From 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 LOCATION____ . __ _,._f'`,__.. :.___�r'��_ f. .��___ Y�L=`: °� _____________ Owner's Name-------------------- £ "�'------------ --------- --W--- ph-------------------------------- one------------------------------------ Address------------------------------- f �- ,f lei ,40 . _ G _ Contractor's Name--------------------------------------- ----- - ------------------------------------------- --------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: `_ tuber of bedrooms � Number of baths 11-_- Lot size _�- '_�..--_-�- - --------------------- Water Supply: Public system Community system F1 Private E] 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 Er- New Construction: Yes Wr--No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publi� sewer is available within 200 feet Septic Tank: Distance from nearest well�4-P._-.._Distance from fo neddation_/Q` Material--- .................___--. No. of compartments-.---__--'''________Size_, 1 _ _: ._ ___:___Liquid depth-__ Capacity___ Q_ _.._ r---- ------------------ Disposal Field: Distance from nearest well_,/4_d1. _-Distance from foundation- ea'.��.A' istance to nearest lot line_. '"�^!�'- - DQ Number of lines-__-----' --________ _____ __Length of each line3V __30:�5✓idth of trench-___2"-7C`r---.--.-_-_-_-_ Type of filter material-_---'�_/�e Depth of filter material_.__�?_..______Total length_______ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits---.------------------Lining material-----------------------Size: Diameter.----------------------Dept h____-_.-__--_--__________- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- 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 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 regulations of the San Joaquin Local Health District. --- - 6 -------------------------------------------------------------------------------------------(Owner and/or Contractor) (Signed)---------- g (rifle) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FqK P411TMENT USE,?NLY APPLICATION ACCEPTED BY.._ r. _ _ _-:t-T .�.e _-'__g__ _:�Z-A--__--._ DATE_ x._ _._ ___� _.__ !,�_. _.___....11 .._ REVIEWEDBY--------------------------------- --------- ------------------------, , BUILDINGPERMIT ISSUED------------------------ -------------------------------------------------------------------------- DAT ------------------------------------------------------------ Alterations and/or recommendations:-------11AT-1RA(Z-------A(.07-Ep------Q ------- 1..................................... ----------------------------------------------------------------------------- ?�/ -' 1c_R.D -. FINAL INS ... ------ ------------ - ----- 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 61 ES-9-2M Revised 8-'59 F.P.Co.