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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 ork h ein escribe . This application is made in compliance with County Ordinance No. 5499... ; r JOB ADDRESS AN LOCATION. _ ""'-c' ff/ G-- -----------` � -- ry 4 , Owner's Nab `"�--�"��---�--`-V-------- � ------ Phone--------------------------------- Address_____.__ ' -f . -�----- ---------------------------• w-- --- ---------------- Contractor's Name--------------------------- - -" �< c� tr1/------------------• Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Co rt ❑ � ❑""Motel ❑ Otliery©� � Number of living units: _:.____ Number of bedrooms ._______ Number of baths_____ Lot size;_____ ------- Water _ rT -- = Water Supply: Public system ❑ Community system Private 0 /De th to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam lay ❑ *Adobe.❑ Hardpan ❑ '� Previous Application Made: Yes ❑ No P--'-New Construction: Yes 91 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: p (No septic tank or cesspool permitted if publicsewer is available within 200 feet.) t � s Se tic T k: Not of compartments ance rom nearest _, Distance from foundation__ems__.___._-Materia. _ - Size_ 5 - Liquid depth - +` --+----Capacity./_;& __________.Distance:to nearest lot Disposal 'eld: Distance from nearest we�,Q+�_�_.�.-Distance from foundation._ � � �� Number of lines---------- -"--- "---Length of each line------��-----------------Width'of trench.._. _••------------••--- Type of filter material _c_ __"-- .___Depth of filter material___ Total Jength_________ ____________ ------------ Seeppag/Pit: Distance to nearest`well l�L�--_______-_Distance-f om oundation_11a._j Distance to nearest lot line__- Lh` Number of pits__-_-/_______________Lining material_�l `�"_.Size: Diameter Depth- ------- Ii t `+Y �R � Cesspool: Distance from nearest well-----------------Distance from foundation________..______--.Lining material____.-_-_____________.___-__ 171 Size: Diameter--------------------------------------Depth----------------------•------------------------I--Liquid Capacity----------------------------gals, Privy: Distance from nearest well________________-----------------.-----------.-_Distance from,nearest building_____________________________ _ El Distance to nearest lot line- � ------------------------- ---------------------- - ------------------- --------------- - ------------------------------------------ Remodeling and/or repairing (describe)--------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- e . ----------------------------------------------------------------------------------------------•--------------• -----------•---------•- •---•-------,-------------------------------------------------------------- ---- -- -------------------------------------------------------------•--------------------------------•---------------------------------------------------------------%-------------------------------------------------------------- ---------------------------"------------------------------- I 1 hereby certify fha+ I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ' a ----- -------- ------- ----------------------------------------------------------- a. gY:---"-----------•----------�_•G? ��"--- caner and/or Contractor -- -----------(Title}- --- - --�-- -------------' -- ----- - - ------------ (Plot pian, showing size of lot, location of system ' relation to wells, buildings, etc., can1belplaced on reverse side). FOR DEPARTMENT USE 9NLY APPLICATION ACCEPTED BY ------------------------------------------------ --- - +----- DATE----------- REVIEWEDBY------------------------ ------------------- ------ -------------------------... DATE----------- --------- BUIL DIN PERMIT ISSUED-------------------------------------------------------------------------- ------------ DATE----------------------- Alterations and/or recommendations----------------------------------- -------------- ----------------------------------------- -------------------•----------------------------- -------------------------------------"-------------------- ------------•--------------- ----------------------------- --------------------- ---------------l---- ------------------------------------------------------------ ------------------------- -------------------------------------------------- FINAL INSPECTION BY:_ Date_.k`.,__ -------- --------- " . SAN JOAQUIN LOCAL HEALTH DISTRICT' 130 South American Street 300 West Oak Street 132,Sycaniore Sireef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M Revised 8-'59 F.P.Co.