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!- MPermit No. ._� 3 APPLICATION FOR SANITATION PERMIT (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 County Ordinance No 549. JOB ADDRESS AND,LOCA ON_. / ----------!-�+ !' ----- -------- f OwnersName------------- -------------- ---------------- Phone----••-----•-•------•----•-----•---- Address_-•---------------- �� ![� -------- i __________ _. _ _ ____________________________________________________________ r =-- Phone...---------------------- Contractor's Name-------- -- `-'--- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /___ Number of bedrooms A- Number of baths _ Lot size ` --------------- ----------- Water Supply: Public system [Community system El Private [j Depth to Water Table ft, Characterof soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8--H"ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No 2R1"1FHA/VA: Yes ❑ No 91� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic•Tank,: Distance from nearest well_________________Distance from foundation-------------------.Material________----_--____-________----_____-________- Ak�r71 r17 No. of compartments------- ------------------Size-------•------------------------Liquid depth------------------------- Capacity-------------------- Dispolsal Field: Distance from nearest well.-------------- -Distance from foundation------_-------------Distance to nearest lot line_____________---. Number of lines-----------------------------------Length of each line-----------------------------.Width of trench- --------------------------------- � �/ Type of filter material-------------------------Depth of filter material-----.----------------Total length-----------------_---------------- Seepage P- : Distance`to nearest well_______-__-_""'____Distance f omI f�o ndation----1!!_ Dista��e to nearest lot l�iny�e-_� -__-__ Number of pits______ ------------Lining material- ��lfi-.--Size: Diameter__ -----------Depth--- Cesspool: Distance from nearest well_____________ _Distance from foundation-------------------.Lining material--------------------------------- Size: Diameter---------------------------------- Depfh_---------------------------------------------------Liquid Capacity- -------------------------gals. N . Priv Distance from nearest well-------------------------------------------------Distance from nearest building----_______________---_________--__-_-. Distance to nearest lot line-------------------------- --------------------•---------------- ----- Remodeling and/or repairing (describe)--------------- � ---- - -------------------•--------------•----------------------------------------- --------------------------------------------------------- ---- --------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done'in accordance with San Joaquin County ordinances, State laws, and rules an regulations of the San Joaquin Local Health District. F � I�# fir Contractor (Signed) f�'r -------- ( 9 ------- -- --------------------------------------------------------------- - - - -- --- ---- (Title)-- (Plot plan, showing size of lot, location of sy a in relation to wells, buildings, .etc., can be placed on reverse side). R DEPA TMENT USE ONLY APPLICATION ACCEPTED BY ---- DATEBY- �Q------------- ---- REVIEWEDBY------------------------------------------------------------------------------- ------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED----------------------- -------------------------------------–------------------- ------ ------ DATE------------------------------------------------------------- - Alterations and/or recommendations--------------------------- --- • -------•-------•---------•--------------------------•------------- G� ------------------ ; .- ------- ---------------- ----------------------------------------- ------ -------------- ---------------- 5 FINAL INSPECTION BY: �r Date--- ----- ------------------------------------- ANJOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street f32.Sycamara.Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California } ES-9-2M Revised 6-'59�-P.CO-