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APPLICATION FOR SANITATION PERMIT Permit No. ... .............. JS . ... (Complete in Duplicate) j �� This Permit Expires ] Year From DateAssued —' Date Issued _______________1_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and Jl the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIO �' �G ?-----------------------Owner's Name--------- rasa-----•------ / -----•-------------------- Z - Pho5ne. - ._ --------.-3---G--- -6---------- •- Contractor's Name -- - - -Q- - ---- ----------- •---------••--------- Phone- -------------- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----1-- Number of bedrooms _ �j�.� �___ Number of baths �-�..,- Lot size _______.___�_ta"-x:2 O d -- r 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 p Clay Loam Clay ❑ Adobe4„ .Hardpan ❑ ' Previous Application Made: Yes ❑; No K New Construction: Yes „k No ❑ FHA/VA: Yes jK No ❑ 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 - /� 7 ------ --. _Distance from oun awn--------_•----------Mat ri I--------------- - � r ----------- No. of compartments--------- --------Size-----, - -_ Y---------Liquid-depth--•------ .----------Capacity------- O p - '� Disposal Field: Distance{from nearest well_ ---D' Lance fro fo oda 'on___-� --- Distance to nearest lot lme___�r._----,--- Number of lines.___. __- +� ,�� ~ f -----------�fgtt /eac lir ----- --- idth of trench--------- ---- - Type of filter material_ -----_Depth of filter material____)_k______._---Total leng#h__________________ -- --- Seepage Pit: Distance to nearest well ____ Distance from foundation-------------------.Distance to nearest lot line______.--._..____ ❑ Number of Pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------- ------------------- Cesspool: Distance from nearest well_________________Distance from foundation --------- material--------------------------- ❑ Size: Diameter-------------------------- ----------Depth------------------------------- - - --- --------- Liquid Capacity_. ---------•--------------gals. Privy: Distance from nearest well_____________________ __________-_--..____._,--Distance from nearest building 1. 9 ------------------------------ j ❑ Distance to nearest lot line 1. d y :: Remodeling and/or repairin (desc `be):----------- -------------- -------------- � . ---- --- ._ r - -------------- , - -------------- _ _ I hereby rtify that I Iiave ” aper this applica}ion and # at the wor ill be done in accordance with San Joaquin County ordinances, #e I ss and rules andj regulations of the San Joaquin Loca`rHealth District. (Signed--------->T---!� _,._ ._�°' ______________(Owner and/or Contractor) BY: -------- ------ ----•-4 ---------- ----- ------------------------------------------------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----------------_ _ _r__. _ -------------------------------------------------------------- DATE- REVIEWED BY -- ---- -------------- -- -- ----------- DATE_------�----•---- �------- - ` -- - - - - ------------------------- UILDING PERMIT ISSUED------------------':--------- - --------------------------- ----------------- - --------`------------------- DATE_--- --------------------------------------------------- Alterations and/or recommendations:--`________ - --•----- ---------------------------------- ----------------------- - ------------- x ----- ---------------------------------------- -------------------------------- --------------- -- -- ------•-------------------- r' FINAL INSPECTION BY:----------------- -------- ----- ------------- Date-------- SAN - -----SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, Caiifornia Lodi, California Manteca, California; . Tracy, California FS-92M Revised 8-'59 F.P.Co: