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APPLICATION FOR SANITATION PERMIT Permit No...Ilkk� - t.v (Complete in Duplicate) D t Issued //////f(P d 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 rdinance No. 549, JOB ADDRESS AN A -- --•--------------------•- OoOwner's Name------ - -------------- Address ---- ---------- ----- -- --- ----------•-----------•---•---•------------ Contractor's Name--- •------------------------------------------------------------------------------------------------- Phone,/�---Q--�%�'Z-74:� Installation will serve: Residence [f—Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms 3--- Number of baths ___I-__ Lot size __.15D -.X i( Water Supply: Public system E&--Cbmmunity system ❑ Private ❑ Depth to Water Table --:ko- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [A—Hardpan ❑ Previous Application Made: Yes ❑ No C8— New Construction: Yes ❑ No [3 FHA/VA: Yes ❑ No [a 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_________________ Distance from foundation -------------------- Material _______________.__.____________________.________- No. of compartments------------ ------Size--------------------------------Liquid depth------------- ------------ Capacity ----------------------- Disposal p sal Field: Distance from nearest well ----- "__.-.-Distance from foundation_._Id________.Distance to nearest lot line_'6_--�_____.._ [ Number of lines- __.________________---------- Length of each line--f[I_�,-________--Width of trench----- ----------------------- Seepage Type of filter material_14�('i4-________Depth of filter material --- length -------- p4________________________ Seepage Pit: Distance to nearest well ____------------ Distance from foupdation---- ,I'O_--------- Distance to nearest lot line -- ------------ Ek _:---______Ek Number of pits --____.-2-x ---------- Lining material ------- —Xt,.(.Size: Diameter ----- kXl--------- Depth ----- r_______________________ Cesspool: Distance from nearest well ----------------- from foundation --- _---------------- Lining material .._____.__.__..____.________________. ❑ Size: Diameter -------------------------------------- Depth ---------------------------------------------------_Liquid Capacity ------------- -------------- gals. Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building .__._._.______.______________..._..__._._. ❑ Distance fo nearest lot line ------------------------------------------------------------------- --------- ------------- ------•------------------- ------ ------------ Remodelingand/or repairing (describe) ----------------------- r ---------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------•----------------------------------- 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, a rules and regulations of the San Joaquin Local Health District. (Signed)------------------------------------------------------------------ -------------------------------------------------------------- -----(Owner and/or Contractor] By:-------------------------- --------------------------------- ----------------------------------------------------------------(Title)-------------------------------------------- .................. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). .. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- : " � —-------------------------------------- DATE---- "r a� ----------------- REVIEWEDBY-------------------------------------------------------------------------- ------------------------------------------------- DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED -------------------------------------- --------------------------------------------------------- DATE -------------------------------------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------------------- _—----------------------------------------------------- ------------------------------ -----------------` --- -� �. FINAL INSPECTION BY: - ---- ------ - Date-------- -7---------------------------------- 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 6-'59 F.P.Co.