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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) This Permit Expires I Year From Date Issued Date Issued ---711 ..__�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and in aUAhe work herein described. This application is made in compliance with County Ordinance No. 549. 11661'-' . JOB ADDRESS AND LOCATION- T�'Li`_. _ sr� fl fe- -.,- .--- -- ---------- ---------- Owner's Name------4_A------- --------------- •---- - =------------------------------------------ Phone-------------------------------•--- l Address - --•---- --- - Contractor's Name--- --...-----• �' ~- ----------- -�1 / ....... Installation will serve: Residen ❑. Ap rtment House ❑ Commercial ❑. Trailer Court ❑ Motel ❑ Other Number of living units: ________ Number of bedrooms ________ Number of baths s3-.- Lot size ____ _ ((�I_ Water Supply: Public system ❑ Community system ❑ Private R Depth to Water Table 1_d__ ft. , Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam E] Clay El1`d*,b'eX Hardpan ❑ Previous Application Made: Yes ❑ No [4 New Construction: Yes IQ No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septictic Tank: Distance nearest - __:Distance m ial__� -'�° [=------------------_ -- Noocom compartments 3---------------Size« LCa acity - _--_- --- i uid de th___ __ Disposal Field: Distance from nearest well_5- _______Distance from foundation----- b--------Distance to nearest lot line________._ Number of lines_______ -____ -_ -Length of each line___ j `° -- -- g - ----- Width of trench " ------------------------ Type �----------------•-- Type of filter materi _ t Depth of filter material____ b`_______Total length__3.�fy------------------------- Seepage ---------------_-- See a e Pit: Distance to nearest we�--------------Distance from foundation P 9 ____________________f]istance to nearest lot line_.______________ ❑ Number of pits------- =.ti------------Lining material----------------------Size: Diameter----------------------Depth--------------------------------- 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 ,4 ordinances, State laws, an rules and regulations of the Sao Joaquin Local Health District. �. (Signed)----.- .1----_ _______________________(Owner and/or Contractor) By-------------------------------------------------------------------------------------Y-----------------------------------------------(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 - - - - ---------------------------------------------------------- DATE-- �l6_-`1 -----------------___ - -- REVIEWEDBY------ -------------------------------------------------------------------- ---------------------------------------.. DATE----------------- -----•-------------- --------------------- BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------.-. DATE Alterations and/or recommendations:--------------------------------------------- - --------------------------•--------------------•-•--•-•--------------------------------------------•----------- -------------------------------------------------- y ---------- -------------------- FINAL INSPECTION /BY: _. ... _._ I� -------------- 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 t ES-9-2M Revised 8-'59 F.P.Co.