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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Qate Issued --------------------� This Permit Expires 1 Year From Date Issued I (—1 D - �3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the worherein described.�r This application is made in compliancewithCounty Ordinance No. 5409. u/,/A/,,` (,,.,( � 3 �OB A©RES A N ON -f� "-- _ v� _..1.._! OUS Rol _:. iVCI-.. j/` Owner's Name-------_---- _ :----- �•--- �' -------- ---------- --------------------------------------- ----- Phone_ [P. _410--- Address � 1 6- ------------------------------------•--------------------•----- --- --------------------- -----•------- ` ----- Contractors Name-------------------� --------- Phone - Q, Installation will serve: Residence C& Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -t----- Number of bedrooms _1_____ Number of baths _.C----- Lot size ��------------------------------ Water Supply: ' Public system ❑ Community system ElPrivate D4 Depth to Water Table -Q- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam A Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes be No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r � SSeptic Tank: Distance from nearest well__S� Distance from faun�ationf�e_ ______._.�teri-f-l_____ __C___a____a__c__i_t_______�___�_----------- No. ___.____ No. of compartments__ _______________Size_______. ©_�-_o -t__Li uid de th__ . E r .Ze--------- �C�-l---- Disposal Fie4d: Distance from nearest well r— _.._.Distance from foundation._ Distance to nearesrt�hotj jne______ _ E Number of lines_____ a Length of each line_$Q__.__ Width of trench-- � ,� - ----- Type of filter material_ __ -----_Qdi -Depth of finer 19------ length____---- r ------------ F Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________Distance to nearest lot line------------------ l ❑ Number of pits-------------- --- -------Lining material-----------------------Size: Diameter------------- -- ----Depth--. -------------------------- Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material---.---------------------------------- ❑ Size: Diameter-------------------------------------Depth--------------------- ---------- ----------------- Liquid Capacity-- -------------------------gals. 41 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.__._.__________----_________._._-__-_._. ❑ Distance to nearest lot line- -------------- ---------------------------------------------------------------------------- -------------------------------------------- Remodelin and/or repairing (describe):------ c.�-------- _ C.--- ---- -- ------------ =---------------- ` t , ---------------------------- ---- - -----------------------------------------------------------------------------------------------------------------------•------------------------------------------------ I hereby certify that I have prepared this application and that th work will be done in accordance with San Joaquin County ordinances, State laws, a ules ndR r,;egulations of a an Joi /Local a Ith D' ict. _ -- --- --•---- ---- --- -m-- -= ---- --- ` - f--- `------- _-_-(Owner nd/or Contractor) (Signed) ---- -- ----- / c rt Title l • ----- -------------- By:---------- -- :-- - -{�--- --------- ------ --------- ---------------{ )- ------------ (Plot plan, showing size of ot, location of system in elation to wells, buildings, etc., can be placlr on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- -------- _____ ___ _� DATE__--- - ---------------------------- �- --- --------------------------- REVIEWED BY------------------------------- DATE_ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:-------------- ------------------------------------ -----------------------•-•--•---•-----------------------•------------------------ ------- ---------- ----------------• -------------------- --------------------------------------------- --------------•----------------------------- -------------------------- •---••--•----- ------------- ----------------------------------------------- -- ----------------------------------------------------- ---------------- ----------- ------------------- FINAL INSPECTION BY---- -------1_1&e�--`-—----------- - ---- Date---------------------- ...� Q------------------------ 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.