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� U n� APPLICATION FOR SANITATION PERMIT Permit No. .//3__7_. (Complete in Duplicate) yz / 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 Ordinance No. 549. JOB ADDRESS AND LOCATION = --=------------------------------------------------------------------------ Owner's Name------ ,� _ --------------------- ------------- Phone------------------- ---_---------- Address----------------------------------- ��/"r '---- -- -- ------- r -------- { ContractorsName -- -----------------•------------------------ ------------------------- ---- Phone.--------------------------------- Installation will serve: Residence �partmen+ House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: At Number of bedrooms _nZ- Number of baths _-1--- Lot size -- , � ------------------------------ Water ----_- ----------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy LoamE] Clay Loam ❑ ClayEl Adobe Er'Hardpan ❑ Previous Application Made: Yes ❑ No 2' New Construction: Yes ❑ No [I!-FHA/VA: Yes ❑ No R;— TYPE ;—TYPE OF INSTALLATION AND SPECIFICATIONS:' ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: „ Distance from nearest well-----------------Distance from foundation------_------.----.Material------------------------------------------------- � No. of compartments--------------------------Size---------------------------- ---Liquid depth--------------------------Capacity--------------------- Dispo�al Field: Distance from nearest well----�'----.Distance from foundation----/P-,......Distance to nearest lot line--_ -�.-... ,e5xG3�-/, f Number of lines----------- .-__ -------- Length of each line_- _ �-------_----- Width oftrench---��F�................... tType of filter material- Depth of filter material_-Xe_ ?---------Total length---------04A.1----------------------- Seepage-Pit:' Distance to nearest well_ ------Distance Distance,ffrprom foundation____12*------- --Distance to nearest lot line_-_+�~r_-- p ��/iNumber of pits-------/--________--Lining material-_je9 --..Size: Diameter_ .J�'jl� Dept n--_-.o2J`---�--------------- �J Cesspool: Distance from nearest well--.r_______---_Distance from foundation-----------------_Lining material-----------------------------------.- ❑ Size: Diameter------------------------------------- Depth-- -------------------- ------------ ------------ Liquid;Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_----._---__-----_------_----.----.------. ❑ Distance to nearest lot line---------- --------------------------------- - -------------------------------- ------- ------------------------------------------------ Remodeling and/or repairing (describe)---------------- '=` ------------------------ ------------------------I--------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,pStwsnd rules d r ations yf +he San Joaquin Local Heal#}� District. Si ned wn r( g )----- -- ----------------- ----- ------- - By------- ----------------------- ---- -- ------ - --------------- --:---------------(Title) -y- / - ------ (Plot plan, showing size of lot, to n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -------------------------------------------------------------------------- DATE--------- .0rJ REVIEWEDBY------------------------------------------------------------------------------------------- -------------------------------- DATE----------------- ------------------------------------------ BUILDING PERMIT ISSUED------------------------------- ----------------------------•----------•----------------=------------ DATE------------------------------------------------------------- Alterations and/or recommendations:---------------------------------------------- ------------------------------------------------------------------------------------------•-------------------- --------- ------ -- --- ----- ------- -- - ----- ----------------------------------------- a ----------------------- ------------------------------------------------------------------- --------------------------------------------------------------------------------------------- ---------------------------------------------------------- fin FINAL INSPECTION BY:------- -(/. 1------------------------------- Date------ Q - -------- -- - - -------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D W-eit qak Sfreat y � ]132 Sycamore Sfree+ i 814 North "C" Street Stockton, California Lodi, California hAanteta, California Tracy, California ES-9-2M Revised 8-'59 F.A.Co.