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APPLICATION FOR SANITATION PERMIT Permit No. Z,---- (Complete in Duplicate) /S^ Date Issued ---_1_41 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 Ordinances No. 549, JOB ADDRESS AND LOCATI - -- -L, ,- ( l; p�^------------------------------------------ JN --------- `- --------------------------- Owner's Name----------------------------F--- ,_ -------- -+ ----- f = one----------------------- -••---- f Address---------------------------•---- � ��- =E ----- Contractor's Name ¢.. �----------- r Phone. Installation will serve: Residence [4partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ { Number of living units: ___�___ Number of bedrooms - Number of baths _J'_. Lot size ---- --- ____ ________________ Water Supply: Public system D�ommunity system ❑ Private ❑ Depth to Water Table ________ ft. 1 Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam [:] Clay E] Adobe ardpan ❑ Previous Application Made: Yes ❑ No ER-"New Construction: Yes 0 Nosgi�FHA/VA: Yes ❑ No ❑� TYPE OF INSTALLATION AND SPECIFICATIONS: { (No septic }/nk or`cesspool permitted if.public sewer is available w_!ithin 200 feet.) Septic Tank: --Frstance from nearest well________________Distance` from foundation----•---------------Material---------------•--------------------------------. No. of compartments--------------------------Size_' _ __'__Li uid de th_______________--- _____Capacity------------------- - ___ Disposal Fi Distance from nearest welL__��_.Distance from foundation__/.r---- --Distance to nearest lot line--00 Number of lines--------------I_ . _ Length of-e'ach� line__---__'1.__a__'._______. Width of french.____�_�__�_�___---------- Type of filter material-------)__� _-..____Depth of filter -___Total length-------- ._---___________________ Seepage P Distance to nearest well___.____-j__Distance frgm-foundation__16)-_f____.Distance to nearest to line_-.�_�--__- I Number of pits____.._-j--------- Lining material-__ J 6 _Size: Diameter___t-3 ____.Depth________________�__________-___ ,�• p _____________Distance from..fou'ndation--------------------Lining material----------•------------_-------____-- Cess❑oo : Sized Diameter nearest well-----------------Depth--------------I-------------------------------� ..Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------------s-----_Distance:from nearest building________--------__________-__________- ❑ Distance to nearest lot " _ l_in�e._._____________ > rr Remodeling and/or repairing describe�.:..___________ _ _ z --•-------------------------- --_-- -----�--�- _.t_— --------- -------------------- -------------------I--------------------- =---------- ---------------------------------------------------------------•-------------- -----------------' --------------------- ---------- E----- ------------------------------- . I hereby certify that I have prepared this appl•ca#ion and that the work will be done din accordance with San Joaquin County ordinances, State laws, and ru and regulations the San Joaquin local Health District. Si ned r l { 9 }-------------------------- -•-�--- --- - --- ---- -�- ---' ---=------ ------------------------k----------------- Owner and r Contractor) / 9 By-------------------- - . --- -- --------- (Title) [Plat plan, showm z of lot, 16cation of system in.relation toiwells. mldmgs, etc.,;can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- _ _ -�-___-'0r---------------- ------------------------------------------------ DATE---_-- _ REVIEWED BY-------------------------------- ------------------------------------------- DATE--- -----------------' r BUILDING PERMIT ISSUED--------•-------------------------- ---------------------•-': - •------------------------------ DATE-----------------------•------------------------- ---------- Alterations and/or recommendations-------------------------- ------------------------------:- ------------------------------------------------------------ ------------------------------------ ---------------------- ------D_L 1<- YAR ' ---------------------------------------- --------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------- _----' I F /,f-_-__1 C,-------------- -------------------------------------'--------•------------'-'---------`-`-------------------- ----------------- --------------------------- 4- } _ 7 i� f "_ _ _ _i; - Y_ —'�_ --------------FINAL IN5PECTlON BY:. -- Y' � -' ---------------- Date _ ' f 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 1-57 FRCO. i