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} y of t APPLIC ,TION FOR SANITATION PERMIT 4k' Permit No. .__rl (Complete in Duplicate) Date Issued 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 ounty Ordinance No. 549. y - JOB ADDRESS AND LOCATION--- -------- �2 '�Q ------------- ----- ------ Owners Name_______ _________ Acf� '� --`--------- -------------- ------------------ Phone ... j i -------------------------------- Address_ 1--------------------------------------------•-- Contractor's Name `- d--------------------•---- Phone ----------------------------------- Installation ---Installation will serve: ResidenceApartmentHouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other (] Number of living units: _1---- Number-of.•bedrooms_ . Number of baths l _- .Lot size _o _ _.-- -1- -�---------------------- � Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table 0--ft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [ KClay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No g�-' New Construction: Yes gj--'No ❑ FHA/VA: Yes V'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS,.--\ (No septic tank or cesspool permitted if fpG�lic sewer is available within 200 feet.) Tank: Distance, from nearest well_[_4_72..�Distance11from foundation_-__-�C_-_--.-_.Material_...._ _ F- ----- --------------- Septic ®� f� __ -----Liquid depth____f -� Capacity..._ G ___ No. of compartments_.__'_. -Size__ ___ _____ _ i s � ation.___h_______._.Distance to nearest lot Number of lines-------- ?__ -� g ' Width of trench_..__' - ---Length of each line! /0 Disposal Field: Distance from nearest well . ____ I 1 epfhcof filter mat' "f Type of filter material--�-,�;,J�� Dep enal_-----�� .--._Total length-----��!_�----------------------•-- Seepage Pit: Distance to nearest well__r.�_ _-� Distance from foundation-_--_ -_.Distance to.Dn epearest lot line__--------- [t}� Number'of pits------------- .LW g material__-_ ___Oe-/C_.Size: Diameter--_ i�"f �y. . th----, --------------- Cesspool: Distance -from nearest well-----------------Distance from foundation--------------------Lining material---------------.___._-.-- -___-. ElSize: Diameter-------------------------------------Depth---•-------------------------------- -------------•-Liquid Capacity------------•-•--------- gals. `Privy: Distance from nearest well--------------------------------------------------Distance from nearest boding-___._.--_---.__------____------___..._. ❑ Distance to nearest lot line-------------------------------------------- =--------------••-------------------------------------------------------- ---------------- r. Remodeling and/or repairing (describe):--= ' --------------------------------------------------------------------------------- ---- --.------,----------------- ------------------{--•----•-----------------•--------•--•----------------- ---------------•------------------------------------------------------------------ --- \ ------- ---------------------- ';_ �s. ! hereby certify that I have prepared this application and}kat'+he-work will done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health Dis+rict. ) (Signed) `" Lu = - Contract Title By: ----------------- ( } + (Plot plan, showing size of lot, location of syste rllation to wells;"b'uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ti I APPLICATION ACCEPTED BY---- e ---------------- DATE"f �� -- � ---------------------- ' 1' --------------------------- ------- DATE _L�-�-l/__�'- ------------ REVIEWED BY--------------------------------- s� BUILDING PERMIT ISSUED_... `" - ------------------------•- ---- DATE •--- --- Alterations and/or recommendations----- --------------------------•----•-- -------•-----------•-------------------------- �, - ------------ f t --------------------- ------------------------------------------------------------------------------------- ........ ---------------------- --------------------- FINAL INSPECTION BY------------- ------------------------------- Date------- If---------------------------------- ------------- SAN ------- -- 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 8-'59 RP.Cc. 1