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APPLICATION FOR SANITATION PERMIT Permit No. O (Complete in Duplicate) Date Issued __�/-Z_!-_ a-__ 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 herei described. This application is made,in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.e t.- �. � j- . -`---- Phone.Owner's Name----- ----------------- ----------------- --------------------------------------------------------------------- L,:, ---------------------------------------------------- `Address.---- --_ � -L - ---- [ # Contractors Name -� � ' : a - R, ��' 49x - �n� __-t�_ ----------•--- Phone.. '..N =� 5' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I.�_ Number of bedrooms __ -- Number of baths ---I---- Lot size .__ - -'1____!__________._ �� Water Supply: Public system ❑ Community system ❑ Private Y Depth to Water Table __ 0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam N Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ PHA/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--------------------------Size---•----------- ---------------Liquid depth-------------------------Capacity------------•---------- Disposal Field: Distance from nearest well________ _____Distance from foundation-_________-.....____Distance to nearest lot line________________- � ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench-.------------------------------------------- W Type of filter material------------------------- of-filter material-----------------------Total length------------------------------------------ Distance __._____________________________.___-__ ' `oa ' foundation-- Number f Seep e Pit: Distance to nearest well____!_____.___-_--Distance froma f[oundation_______L� _ __.Distace to nearest lot line____ Number of pits------I--------------Lining material_.,!- .__.Size: Diameter__ '- ...............Depth__,Z.:-?__ _____--_____-_--_ r 3 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------.________________ ❑ Size: Diameter-------------------------- -----------Depth-----------{---------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------- from nearest building------------------------------------------ 0 Distance to nearest lot line----------------------------------------------------------------------- -------------------------------------------------•-------------------- Remodeling and/or repairing descri a =-------------=----- `'�------------------•-------------------- ---- -- ------------------------------------------------------------------------------•---•------------•-•-------'-------•--•---•------------------------------------------------------•-------------------------------- ------------------------------------ ---------------------------------•--------------------•-----------•---------•--------------•-•-----------------------------------------------------•------------------ - 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. fi -- - r ! 0 (Signed)-° d� ._ ------- eContractor) - 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 ----------------------------•- ------------------------------ DATE-----f---------`- REVIEWEDBY------------------------------------- ----------------------------------------------•------- ------ DATE-----------------:------------------------------------------ BUILDINGPERMIT ISSUED-------•------•-----------------------------------------------•--------'-- ---------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:------------------ ------------------------------------••------------------••--------------•--•-••----------••--••---------_.-------•-----------------•------- ------------------------- --------------------------- --------------------------------------------- ---------------------•---------------------------------------•---------------------------•------------------------------- ------------------ ------ ------- ---------------------- --------------------------------------------------------- ---------- ----- ------------- -------------•---- -----------------.-:--_---- -- --- ---------------------------- ----- ------------- ---------------------------------------------------------------------------------- ` ?'�d FINAL INSPECTION BY: - -- ------------ 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 ES-9-2M Revised 6-'59 F.P.Co. -