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30 APPLICATION FOR SANITATION PERMIT Permit No. _.1��.........__. (Complete in Duplicate) Date Issued ____ �S __.�� r� This Permit Expires 1 Year From 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----- ----------------- � -------- ¢ Z-4 ------------------------------------------------------------------------------------ Owner's Name------------------------------,...•---•----, � -- -------------------------- -- f / ---------------- Phone--- Address -- Address-------------------------- -- -------------•-------------- --------•----------•------=-------------------.......... Contractor's Name--_1i C=�-------------------------------- 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 ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobe4 Hardpan ❑ Previous Application Made: Yes ❑,, No-i�;t New Construction: Yes' No ❑ - FHA/VA: Yes ❑ Nov TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_llnr , Distance from foundation-_ /D________...Material_____e �• --- ._� • '._47 _ A No. of compartments _Size- 3_Li Liquid de th_____ _`� -Capacity- Disposal a acitY Disposal Field: Distance from nearest well.A!2aDistance from foundation----Z0---------Distance to nearest lot linQ______,5 . i Number of lines_____________ --.,...,--Length Length of each line---- � `--------.Wid _th of trench._____. /-- ------ Type of filter material___, __Depth of filter material___.____- -�__---_Total length__ _____ �x_CI_ e i i ante o neares n a ion rr �r .ri 1 Number of pits- ------ ----------- g ma e`ri al_ � Y lame �.,_.--- --•-_ Cesspool: Distance from nearest well{----------------Distance from foundation.------------------ material _------------.____________.__.______- ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals! _O Privy: Distance from nearest well---------I-______________________________________Distance from nearest building___.._______________________..__--_... ❑ Distance to nearest lot line--------- ------------------------------------------ ---------------------------------------------------------------------- _._._. Remodeling and/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, Stat&jqws,,and r es and regulations of the San Joaquin Local Health Distric+. (5i ned _ o~C+ _______________._____- .Owner or Contractor) g ) --------- - --- -------- ------ ------------------- ------------------------------------------ sY:---•--------------------------------------------------------------------- ---------- ----- -------------------------- ------------(Title)------------ - ------r- ----- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR EPARTMENT USE ONLY APPLICATION ACCEPTED BY 44' -4---- ---- -------------------------------------- DATE--- �f' 1�0--------------------- REVIEWEDBY----------------------------------------- - - -----------------------------•------------------------------------------------- DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------—-_------------------------------------ DATE--------------- ---------------------------------------------- Alterations and/or recommendations----------------------- --- ------- --------- —` -------- -------------------------- ---------------------- ------ --- - -------------------- % � ----------- - ------------------ ------------- ---- -- --- ------------------- - - - --- -------------------- -------------- - --- -- --- - ------ -- -�----------------------------------------------------------- ----- ------ - --------- -------- ------------------�`-------------------------------- ----------------------------------------- FINAL INSPECTION BY:.. ------------------- -- Date--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfree4 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised 6-'59 F.P.Cu.