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, Permit No. APPLICATION FOR SANITATION PERMIT (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 work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----, - -----L� '----------------------------------------------------------------------------- Owner's Name S 7 ------------------------------------------ ------------ -- Phone.................................... - Address----_---efix--. '-------------------•----------------------------.....-•------------------------------------ Contractor's Name----------------------- ?4:P,or?'--------- .-------------------------------------------------------------------- Phone................................... Installation will serve: Residence 2fApartment House ❑ Commercial ❑ Trailer Court ❑ Motelr❑ Other ❑ Number of living units: _.r<____ Number of bedrooms . ` _ Number of baths .f___ Lot size .....,oe;Z1 __.�f'f' ...................... Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 5R` New Construction: Yes ❑ No e— FH'A/VA: Yes ❑ No JR-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ,r� tfc Distance from nearest well_-______________Distance from foundation--------------------Material --__-____.___--._-_-._.-_-___-_-._---_--___-. ' n, No. of compartments--------------------- ----Size------•--------•------------- Liquid depth--------------------------Capacity-•--------------------- U�p§S 9jd: Distance from nearest well-------- --_--Distance from foundation..../Of__........Distance to nearest lot Number of lines___.__.._..__.J___ ._-___ Length of each line____ _� Width of trench____ __�' C> Type of filter material.f 41�_Depth of filter material-__L` _______..Total length._____%0—X.-__.._:7„_____-___--_ Seepage Pit: Distance to nearest well-------- f m foundation___.eO�.____.D's ance to nearest lot line------.P".. � </ —i Number of pits--...4-------------Lining matenal._ _�_fjC'--__-Sizer Diameter_ _ //_-----Depth__,�s1_____________________ � Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--._____----____----__-___--_-_--__--. ❑ Size: Diameter--------------------------------------Depth----•-----------------------------------------------Liquid Capacity------------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------__..__-__.-__.-_-....___--__-____.-. ❑ Distance to nearest lot line----------------------------- --•-----------------------------------------------•------------------•----------------- RXl� emodeling and/or repairing (describe :---------------- 'f�'Z'_ ---------------------------------------•------------------------- --------------------------•--•--------------------------------•------- f -------� ----------------------------------------------------------------------------------------------- ------------------------ ----- --------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------- 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. (Signed) -------------------- By: 7 t ( _ /or Contractor) - ------------------- By:.--•------------------•------------••-----•-------------------- = — --------------- --------------- ---------- ------------------- (Plot --------- (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------a-- ------ ------------------------------------------------- DATE----------------V -- - REVI EW ED BY - - -------- DATE BUILDING PERMIT ISSUED----------------------_------ ---------------------------- ---------------------------- DATE-------------------Alterations and/or recommendations-------- ------------------------------------------------------------------------------------------------------------- ------------•-................... -------------------------------------------------------------------------•--------------•-----------------------------------------------------------------................................ ------------------------------- -1-------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- ---------------•------------ ----------------- -------- -------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------ -- -- FINAL INSPECTION BY---------- ------ -- ------ Date------ J ---------------------------------------- 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 8-'59 F.P.Co.