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APPLICATION FOR SANITATION PERMIT Permit No. .--Ap (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ..-------------- ----- Application plication 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 Cmy Ordinance No. 549. JOB ADDRESS AND LOCATION------------- --- -- rxc- �__- fcA•,-,� ,-----_ Owner's Name---------- ��1 } = L� _ �- t ��— ----------- ----- ------ Phone `5--- ------- � Address------••----•----------••------ - Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone------ ---------_---------------- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .../--- Number of bedrooms -3--- Number of baths ----/_ Lot size --------- _J-0----X e - ------'�-------•----------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table _2—rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeZ Hardpan ❑ Previous Application Made: Yes ❑ No 12, New Construction: Yes ❑ No E& FHA/VA: Yes ❑ No r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SepticlTank: Distance from nearest well-----------------Distance from foundation--------------------Material-___________._-_.--.--_\__._.,._._._-___-_ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacit� -;--- Disposal Field: Distance from nearest well__----__-_Distance from foundation------,�_P____.Distance to nearest lot line----- --------- Number -------Number of lines__________________ __ Length of each line___--- _ ...... Width of trench----_-- -i -- Type of filter material___ __r-_,/,L-Depfh of filter material '." Total length....__._..1/_�__ -_----------. W eepage Pit: Distance to nearest well-------__- -------Distance fr. m foundation---/_Z�...Distance to nearest lot Number of pits---------/----------Lining material--,/ Diameter._.,-?,,;� -----Depth-------- -----_--__---- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material------------------------------------- El Size: Diameter------------------------------- ------Depth----------------------------------- -------------_Liquid Capacity- - ----------------------gals. Privy: Distance from nearest well--------------------------------------.------..._Distance from nearest building-----------------------------------------I ❑ Distance to nearest lot line----------------------------------- --------- - ---------------------------- --------------------------------------------------------------- - Remodelingand/or repairing (describe);-------------•-------------------------------------•-----------------------•------------------------------------------------------- ------------------- -----------------------------------------------------------------------------•----------------•---------------------. ------------------------•---------------------------------------------------------------------------- - - -------------------------------------------------------------------------- ------------ ------------•----------------------------------- 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 fhe San Joaquin Local Health District. (Signed}-- _, _ y_d-i�1r`__L_.�� ------------------ �" ____________________________-___(Owner and/or Contractor) • ------------=�--------•-------------------------•--------------------------------------------------------------------(Title)--------------------- -------------------------- ---- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). F DEPARTMENT USE ONLY �. APPLICATION ACCEPTED BY------ ----- `-��-''��------------------------ •- --- - ----�`-'-�--- - - ------- -- -- •-4-�-�= -- --- -- - --------- DATE---------------- -�,� REVIEWEDBY _ - -------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------- --------------------------------------------------------------------------------------.- DATE.---- Alterati s a d/ r recommendations:----------------------------- ---------------------------•----------------------- - •. --------- -------------- - _ �• /,P� __ .__.___.--ter__- .._�� }!_�-�4v.0 --------- ------------------------------------------------------ -•-� ------------------- N $Y:.----- ;�-- - , Date ��J~~ - --- ----- {' SAN JOAQUIN LOCAL HEALTH DISTRICT ,!60 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street L. Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8.'59 F.P.Co. /