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g .1.1Lq( 60 i APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Expires 1 Year From Date Issued 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 Or anc No. 549. JOB ADDRESS A 1�- CATION.____ -�.? Q_ Owner's Name----_--- --------- Phone_ = i L- 42) Address - - -- ------------------------------------------- -------•-- . --------••-- •--••---...---- Contractor's Name------------ ------------------• --- ----` -------------------------------------- Phone............ ---.. _--------- Installation will serve: Residence Apart n} House ❑ Comme'rcial ❑ Trailer Court ❑ Motel ❑ iOth/erS❑ Number of living units:,,_____._ Number of bedrooms Number of baths ____I�_- Lot size ___ _ ___-_-_____l--v�__�__-______.- 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 ❑ Clay Loam ❑ Clay E] Adobe'�Hardpan ❑ Previous Application Made: Yes E] N�New Construction: Yes E] Nd FHA/VA: Yes ❑ NZ< TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public/sewer is available within 200 feet.), Septi Tank: Distance from nearest w __ *-Disfanc from faunda 'on_-_ Ma ��al Liquid d -� - Capacity f No. of compartments-- - ------- ySize q P p tY Disposal Field: Distance from nearest w LI_. --- -------- Number lines--- Length ------------ Type length______ __ ______-_________-- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line_--_----_-_---_.- �fll ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------.-------------------------- Cesspool: Distance from nearest well----------------- from foundation____.------------- Lining material-----.._________________________.__. O ❑ Size: Diameter----------------------------- -------Depth----------------------------------------------------Liquid Capacity---------------------- -----gals. Privy: Distance from nearest well----------------------------------_--------------Distance-from nearest building----------_-------------------------------- C ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-------- ------------- ------------------------------- --------------------------------•--------------------------------------------- ----------------- ------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- s ---- --------------------------------- ---------------------------------------------------------------------------------------------------•------------------------------------------------------------------------ - 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State}la s, and rules and regulatio s of the San Joaquin Local Health District. (Signed)__0 -- _ -----------------------------------------------_--------------------------------------- -(Owner and/or Contractor) By:----------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------- - -- .................... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR EPART ENT USE ONLY APPLICATION ACCEPTED BY-------------- ---- ------- -- --------- - ----------- -------------------------------- DATE --- REVIEWEDBY----------------------------------------------- --- - ------- - --------------------------- --------- DATE--_-_6--------------------------------------------------- BUILDINGPERMIT ISSUED----------------------- -----------------------—----------------•-------------------.- DATE--------------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------ ---•------------------------------ - - ---- .......- --- ---------- - --- - ------ ---- ---��-------rte-- -f�-�_ -----;��- --- - ---=- - � ------ --------------�--e-------- -�------- --------------------------.--------_ ---------------- -------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 6 FINAL INSPECTION BY:- ---- :------ -t'----- Date____-/ -__ _ .� ��C� - ----- -- - -------------------------------- 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&'59 F.P-Co.