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� APPLICATION APOR SANITATION PERMIT Permit No. ..1..r�.:�.� s ro:- e1 . , A (Complete in Duplicate)- - 7/1 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 work herein clescrmed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN LOCATION__---------��_��_.__ . _ � - Owner's Name .- -, ------- Phone-------------------------------- Address ----- ;= AContractor's Name ` ----------- Phone __7..... _ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Traile ourt ❑ Motel ❑ Other L✓ w�� Number of living units: ________ Number of bedrooms ___:____ Number of baths____ .Lot size ____ ___ __ ____________________ 4 Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe 2 Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes P91'<o ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: l (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) Septic T k: Distance from nearest well 7____ ___________Distance�•-7fr9yn fou ction___ -------Ma er'al___. _. _ _._._ ______.__.___ No. of compartments__._______________Size_____ C`___s __.___Liquid dep%h__gr��_...__Capacity__yi�___--__ Disposal •eld: Distance from nearest well %_.Distance from foundation_AS_--------Distance to nearest lot line------_67--_--__- Length of each line_____�a_ _ _ , Number of lines___._______________ _ _ ___________Width of trench.___�r�_ ____-.---_ ._._ 41� Type of filter material-_!9_L _.__. _Depth of filter material-----Ile_.______.Total length___13 ----------------- Seepag __ _ it: Distance to nearest welllw_w_..___Distant om oundation__v�r�•.______.Distance to nearest lot line--- Number of its_____ ______ _____Linin material_ .__.Size: Diameter_..__ _.�.._._ Depth_____ ------------------- Cesspool: _Cesspool: Distance from nearest well-______________Distance from foundation Lining material______________________________________ 0 Size: Diameter--------------------------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. 'Privy: Distance from nearest well---------------------------------------------------Distance from nearest building------------------------------.___-____. �I ❑ Distance to nearest lot line------ ---------------------------------------- ---------------------------•-•-------------------------------------------•-------------------- Remodeling and/or repairing (describe)------------------- ------------------------------------------------------ ------------------------•----------------------------------------• -------- -----------------7----------------------------------------------------------------------------------------------------- - ---- --------------------------------------------------------------•--------------------------------•--------------•---.---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------- -------------------=---------------------------------•---•------------------------------------------------------------------------------------••-------- -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Si a ws, and rules ajegulattions of the San Joaquin Local Health District.[Signed) - ---G --¢- -------- n ----------------------------------- _ Owner and/or Contractor) - t gY: (T'itle� _ - --------•---- .----------- (Plot plan, showing size of lot, location of system m relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------' DATE----------- _'_�`.-- -u_�'------------------- -- - ---------- -- ---------------------- REVIEWED,BY`--'-`--------------------------------------------- -- ------------------------------- -------------------------------------- DATE----------------------------- BUILDING PERMIT ISSUED----------------- -------------------- - -------------- DATE-------------------------------------------------------------- ----------------------- and/or recommendations-------------•---------------------------`----------------------------------------------------•------------------------------•-•-------------------------------- ----------•-----•---------- -- -•--- - ------------- .. - y ate= Q ; = 5%�r � �o�r r�Ir �/ -------------------------------------------------------- x - ------------ -------- -------- - p FINAL FINSPECTION BY:- � ` _ .. Date...... 5 rte' -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street r Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.co. r