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APPLICATION FOR SANITATION PERMIT Permit No. __C� .. .._.. LJ (Complete in Duplicate) Q This Permit Ex ires 9 Year From Date Issued ate Issued J�7 This Application is hereby 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. _ /�//�. i0600 JOB ADDRESS AND IOC/ATION--- y� ;� * 1 Fy —.�._: �'� �� r ': _ ------- Owner's Name------------ ------------------------------ ---------- -- Phone- Address-------- hone_Address------- - - - ••--- -_ ---------- = ; / ---- t--•• ---------------------------------- - Contractor's Name___ =. -------• ----------------------- ------------• -------- ------------------------------ ---------••--- Phone ---- --•--��-�-�-� . Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: _ ___ Number of bedrooms >�"--- Number of baths -_ Lot size Water Supply: Public system ❑ Community system ❑ Private1' Depth to Water Table Ao_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan C]Previous Application Made: Yes E] NO New Construction: Ye No E] FHA/VA: Yes ❑ No ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool.permitted if public sewer is available within 200 feet.) w r Septic ank: Distance from nearest well----------------- from foundation-------------------Material------------------------------------------------ ----..______._______--- __._ - - ------------- No. of compartments------- ---- -------------Size_.------------------------------Liquid depth---------------- ---------Capacity----------------------- Disposal F Id: Distance from nearest well... _ Distance from foundation__ _.�___._-----Distance to nearest lot Number of lines____ __________________ __ Length of each line____ -----------------Width of trench___ _. ._ _ /_________- Type of filter material _________Depth of filter material-__ _Y---��- _.Total len th-_____ _ g -------------------- Seepage Pit: Distance to nearest well_____ ______________Distance from foundation-------------------.Distance to nearest lot line______________._• ❑ Number of pits----------------------Lining material------ ------------..Size: Diameter-----------------------Depth----- ------------- -- Cesspools Distance from nearest well ___________------Distance from foundation------------------- Lining material-___..._--__________________-_____. Size: Diameter - ------------------Depth-------- ------------------•- --------------------Liquid Capacity-- -- gals. Privy: Distance from nearest well--------------------------- ---------------------Dista e from nearest building--'-.-' ❑ Distance to nearest lot line----------------- Remodeling,and/or repairing (describe):_.. - ----- --------- ---------------- ------------------------------------- -----------------------------------------------------•-------------------_---.-----------------••-----k-----------------------------------------------------'------------ ---- -- I hereby certify that 1 have prepare his application a d fha `the work will be done in accordance with San Joaquin County ordinances, S law d rules a r ations e S Jo in Local Health District. (Signed ---- -- --- w ------- - ------ --- -- - -4-- e (Own d/or Contractor) �By------------- -- Title ------------- (Plat plan, show! size of lot, location of system in relation to wells, buildings, etc., can b ae-e- on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY '-------------------------------- DATE------ E REVIEWED BY ----------------------------------- DATE _-' BUILDING PERMIT ISSUED DATE----------------------- - - 1 Alterations and/or recommendations:---------- --------------------------------------------------- -------------- Q . ---------- ----------------------------------------------------------------- --------------------------------------------------------------------•----------•--------•-----------------------------•-------- -. ----•------- ------------------------------------------------------------------------------- -------------------- ----------------------- ----- - ---•------------- - f ------ _t, FINAL INSPECTION BY-------------- --------•--------------- ------------------- - Date-------------------- -'------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 8414 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California FS-9-2M Revrsed 8-'59 F,P,Co. r 1