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APPLICATION FOR SANITATION PERMIT Permit No. . .-.. (Complete in Duplicate) Date Issued -'-!0,/ This Permit Expires 1 Year From Date Issued Cps S---f3e 03 k 1 Application is hereby made to the San Joaquin Local Health District fora permit to construct and -install the wor herein de crib This application is made in compliance.with Count Ordinance No. 549. w. �11c, /� ---- ----- JirSB ADDRESS AND LOCATION--, e �� r Owner's Name---- "��C4�if, -------------� Phone- _1_ ,�_7 # -? -.S 7-------- Address ----------------------------------------- -•-- ------------ ------------------------------------------- Contractor's Name " Phone__ . S - - - Installation will serve: Residence A-- Apartment Mouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/.__-- Number of bedrooms zl--- Number of baths '�__ Lot size __-��---� --•-------•--------------- 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 ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes, No ❑ New Construction: Yes ❑ N0FHA/VA: Yes El El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--------------_-Distance from foundation__._-_______.______-Material------------------------------------------------- ------------------------ ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity II _________________Distance from foundation--------------------- Disposal Feld: Distance from nearest wectnearest lot { ❑ Number of lines-----------------------------------Length of each line--------------------!---------Widthoffre chine----------------- Type of filter material____-________------_____Depth of filter material_____-----------------Total length-------------------------- i Seepage Pit: Distance to nearest well �—____ _.___.____Distance from foundation- ,[--------Distance to nearest lot line__��_____._ _Lining material___ Ao ' I, .Size: Diameter______; -------------- Number o4 pits.---------1------ -- - - Cesspool: Distance from nearest well-----------------Distance from foundation-------- -------------Lining material------------------------------------- i .� ❑ i.. Size: Diameter--------------------------------------Depth ---•--------------------------- -----------------Liquid Capacity- --------------------------gels. Privy: ` 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 and regulations of the San- Joaquin Local Health District. (Signed)! - A-1-1-Z;- ----- ------- - ------ -------- /or Contractor) .- (Title) ---- ---- ----=-------- BY:--- ---------------- --- - - (Plot plan, showing size of lot, location of system relation to wells, buildings, etc., can be placed on reverse side) f FOR DEPARTMENT USE ONLY / y APPLICATION ACCEPTED BY_ y ------------------ -------------------- DATE_�ar/ - - REVIEWEDBY--------------------------------------------------- ------------------ --------------•--------------------------------------• DA ------------•---------------------------•--------- tBUILDING PERMIT ISSUED---------------------------------------- --------------------- DATE-------------------------------------------------- Alterations and/or recommendations----------------------- --------------------------- -------------••----------------•------------------------------- -----------------------------------------------------•-------------------•-•----------------•-------- -------------- ------ ------------------------------------------------------------------------------ ----- ----------------------------------------------------•-------- ------------------------------------------------ ------------- FINAL INSPECTION BY• --- ----------- -- -------------- Dafie 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 E5.9-2M Revised 8.'59 F.P-Co. «..FF