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APPLICATION FOR-SANITATION PERMIT Permit No. ._2_$2.......,7.6 {Complete in Duplicate} �l�j/ 0 This Permit Expires 1 Year From Date Issued Date Issued .__.___!__!__ __4� Applicationlis , by 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. � a w.. JOB ADDRESS AND CATION ;/ � /-4. Owner's Name `' ----------� �--------------- -------------------------------- ------ Phone, x ---4 ----------------------------------------- --•----------- ----- Address----------- Contractor's Name-------------------- --------•-•------.------ Phon _---v� (- Installation will serve: Residence ❑ Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other t� ' Number of living units: -------- Number of bedrooms .__'-,__ Number of baths -------- Lot size _ _ ___ __«__-__-____.____.. Water Supply: Public system P-l"r-ommunity system ❑ Private ❑� Depth to Water Table 7=�ft. �. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E� aardpan ❑ Previous Application Made: Yes [I No w Construction: Yes ❑ No ❑ FNA/VA: Yes ❑ No ❑ _` i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer s available within 200 feet.) anl�- Distance from nearest well_________________Distance from foundation--_i -----------Material------ _ No. of compartments--------------------------Size---------------•------`._____.Liquids;clap+h__.______.--__.-----------Capacity______-_•--------__-_-- ield: Distance from nearest,well-------------------Distance.from foundation____`-.__--___\�.Distance to nearest lot line___________ Number of lines-----------------------------------Length of each line-------- ----`--------':Width of trench-------1----_--------------------- _ Type of filter material-------------------------Depth of filter material-----------------------Total length--_----------Y-.--.-----------_--------- (Pf A' Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---__--.__.____-- r ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------N,----------Depth-------,---------------------- 0 Cesspoo€: Distance from nearest wefl-----------------Distance from foundation....--------------- Lining,,_materia l-----.__-'_-___._..______-____...__. ❑ Size: Diameter Depth = Liquid 'Capacity, - -----gals. . t � - Privy: Distance from nearest well____________________------_-------------------.#D.istance from nearest building_____._ti----.._______.______.._._______El . Distance to nearest lot line 4 ........... ----•-------------- ------ a_lt�., - Fir -• . Remodeling and/or repairing (describe):------sljtca-------- -----------�. =fr 4 _c s----- 4 ,- 4 A ----•- ----- ' ------------------ ---- ___ _____ ___ E f - I hereby ertify +hat I have pre aced this application and +hat the work-will a done in accordance wi+hj-San.Joaquin County ordinances, laws nd rules reg ti ns of th an Joaquin Local Health District. (Signed) t � , a ` - 4 ' w and/or Contractorl ner BY= -------------------------------- - ----------- (Title) __rl {Plot plan, showing size of lot, locationpofsyste�m relation + ells, buildings, etc., can be placed on reverse side}. • ) i :•� FOR DEPARTMENT USE ONLY it APPLICATION ACCEPTED BY--- �___� -� f - _c4-i ------------_----------- DATE---- L�= _ --------------------- REVIEWED BY------------------------------------------ ----------- DATE '=' ' ------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- ---------;`------------- DA•TE-------------��,-.< -.1; - -------------------- Alterations and/or recommendations--------------------------- --------------------------•--------••------------------------•----------•------•-------.---------•----------•----'-= ---------------------------------------------------•---------•---------------------------- --------------------•-•----------------------•----------=--•--------------••------------ ---------------------------'------------- ----------------------------- ------------------------- -------------------------------------------------------- ------- ----------------------------. -r FINAL INSPECTION BY:---- - .- / T� r�a� Date-----J Z/ �O G SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Street 3D0 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F Co.