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APPLICATION FOR SANITATION PERMIT Permit No. ._1................... (Complete in Duplicate) Z 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*wit County Ordinance No. 549. ' JOB ADDRESS AND LOCATIO i - A ---------- ------ --- ---- -- Owner's Name----------------------- --------- •---- - -•+. * '°-------------------------- ----------- Phone ` Address---------------------------- 1------ - --------- Contractor's -------Contractor's Name------------------------------ ---------------- ------------------------------------------- ---------------------------- ------ Ph ne------------------------------------ Installation ----------------•----------------Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote Other 0 Number of living units: _�.-._ Number of bedrooms __ Number of b the _ - Lot size --- --- --- -----_ _._r ... ------------------- Water Supply: Public system ❑ Community syst E] Private Depth to Water Table: A t Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Jay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No W'*—New Construction: Yes to ❑ FHA/VA: Yes ❑ No ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) T--100 /��tw�� Septic Tank: Distance from nearest well_i ___-_-.__ isiance from --- _ founda_tion--_ M --_-__. _ :;.r._ No. of,compartments-=-=- –"`�--�._-: Size/�,X--!- - -- ?,=--Liquid,dep h..-- -----------------bapa thy-- 0 `i!—Z-. ----__. Disposal Field: Distance from nearest well�(s_ .____ -- is`tance from foundation--tj - '""Distance to nearest lot _.__ Length of each line_ Q Width of tren h�- pay --_-__--._ Number of lines.-_..____ g ,7-�---�- - -- --- --- Type of filter material__ _ Depth of filter material___.. H Total length_-__ _____--___--_-_- I Seepage Pit: Distance to nearest well____-----------------Distance from .foundation---_-:--__-_---._--. +istance to ne}reat lot line...____.______._- ❑ Numb6r of pits--------------- ------Lining material----------------- ---- Size: Dia meter -------------.- Degtn--.------------------------------- Cesspool: Dista ce from nearest weif________ Distanc4from(foundation-------------------- material_______.-.--_---_--.- _-- ❑ Size: Diameter--------------------------- ----------Depth--------f--- -------------------------------------Li uid Capacity- --------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-----.-_.------.__----____-------.--___. ❑ Distance to nearest lot line---------------------------------------------------------------••------ ----------t--------------------------------------------------- r ----------•-•-------------------------------------------• ------------•---..._..-------------------•--------------- Remodeling and/or repairing (describe) ��q_.___.--------_-_ - ------------------------------------------------------------•---------- -----------•------------------------------------------------•---------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S [law, and rebs d r u a ions of the San Joaquin Local Health District. (Signed) - -- ------------- ---------------- _ _ _ (Owner and/or Cont. ctor).,��^ Tia ---- -(PloBy:-----------------I--------------------------------=---------------------------------------------------------:---------------- (Title)-- -----------I---- ------------- ----- ------ ---------------- (Plot t plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r F DEP. T U ONLY I = . . f APPLICATION ACCEPTED BY ------- - :,,.: ATE--- REVIEWEDBY---------------------------------------------- -------------------•-------------------- ------=------------ ----•------------- DATE.----------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------–---------------------- --- ---- DATE--------------------------------------------- --------------- Alterationsand/or recommendations------------------ ----------------:-- ------------------------------------------ ------------------------------------••-----------•--------------------------- ----._----..__--------------_-_-_-_----------_._------..---._----____.-_-.__-_____--_------_.--_-.-_------..----_-__-_-....--_---.-___-_•..-----------.._..___-___-----_-..__-_-----_----.--------__-_---___-----_-----.------. J i ---------------------------------- ------------------- ------------------------------------------------- ----- --- ------------------------- --------------------------------------------------------- --------------------------- _----..----------.. FINAL INSPECTION BY------------- ---------- . Dafie / �` -- ---- - ------------------------- I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M., Revised 8-'59 F.P.0O3 , J