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APPLICATION FOR SANITATION PERMIT Permit No. ../s5. . (Complete in Duplicate) Date Issued ----1 4 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 549., „ JOB ADDRESS AN LOCATION..___ /___�_l 1 -- --=-- ----- -----•• ------ ----- Owner's'-Name- ----------- Phone----------------------------- ------------- _ -_--------------- Address---- ._.. ; Contractor's Name------ __�_�;_----- - =��21�----�- t--- -- ----- • - --- --------- --------------------------------- Phonet--- - ----- ...-- Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer.potus" t ❑ Motel [I Other [DNumber of living units: -------- Number of bedrooms _____.__ Number of bath _____ ize ____-. --• --------- Water Supply: Public system ❑ Community system ❑ Private 93"'Depth to Water Table4?—Xft. h Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No E_ lJew Construction: Yes ❑ No ,FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) #4 i k Distance from nearest well-_______."____.__Distance from foundation-----_--------------Material_________-_____.__-___-_____________--_-________- No. of compartments------------------i------Size-------------------------------Liquid dept--------------------------Capacity----------------------- Disposal Field: Distance from nearest well/A0___tDistance from foundation___A9 !_Distance to nearest lot line_lege_.._ N „(dumber of lines------- Length of each line_______, Width of trench__.__ _ ____-- "-�______.__ Type of filter material_ _ --Depth of filter material------ length_______-_-______-as------------- Seepage P' : Distance to nearest well-/'#p_ --_______Distanc om foundation_"� Q____..Distance to nearest lot line Ell t number of pits-------- ------ --Lining material_A ".__.Size: Diameter--- -----------Depth-._ �-------------- ---- Cesspool: Distance from nearest well _______________Distance from foundation--------------------Lining material----------------------- +� ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Z Priv Distance from nearest well-----------_-------------------------------------Distance from nearest building---------------------------------------"_. 0 ❑ Distance to nearest lot line------ ------------------------------------------ -------------•----------------------------------------------- ---------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------- ----------------- -------------------------------•----------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------••---------------------------------- __ --- --------------------------------------- ------------------- ------------------------ ----------------- - --- -- ------------------------ --- ---------------------- _- ---------------------------- -------------- I hereby ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, t t aws, nd rules regulations f the San J quin Local Health District. (signed}- ��. -- - - ------- -- --` - ---- -- Owner and/or Contractor) -- Tale - ---- -- -------------- By:-----------------------_------------------- { (Plot plan, showing size of lot, location of system in relation to s, Wings, etc., can be placed on reverse side). �--^{? FOR DEPA MENT USE ONLY _ "1___a l APPLICATION ACCEPTED BY" _,c---- ----------------------------------------------------------------- DATE------- ------------------- REVIEWED BY-------------------------------- - --------------------------- -------------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------•---------------------------------------- DATE.------------------------------------------------------ Alterations and/or recommendations: ---------------- ------ F----------------------- y.[._ ------ ..._ ------------------ ---- - �i�------- 1>7------------ -- --------- `�---•-- �A ------- �V.-".-----T.-R, ------------------------------------------------------------------------------I----------------- -----------1-410--� - ------------------ FINAL INSPECTI Date _ ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West 0A 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.