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i APPLICATION FOR SANITATION PERMIT Permit No. •!-!_.5.-3 .... (Complete in Duplicate)' " This Permit Ex ires ] 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. f This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-_-___-_ rv_ --- -- ----------- ------•---------------------------•---- -----••-------------- Owner's Name - ------------- •------ ----- Phone_-------------- - - -------- Address •-------------------------- =-•------------ Contractor's Name_ ��' .. --- --------------------------------------------------------------------- Phon ....7_:--a l_� Installation will serve: Residence Apartment House ❑ Commercial p Trailer Court ❑ Motel p Other ❑ I Number of living units: __ __ Number of bedrooms .`�__ Number of baths _ ___ Lot size __*7. - _ , ,.,T Water Supply: Public systemCommunity, ysterm El -'Private E] Depth to Water Table .'__:ft.- Character of soil to a depth of 3 Community, Sand [) Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe& Hardpan ❑ I'I Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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 compart 4 encs --- ---Size--------------------------------Liquid dept}------------------- - -Capacity-------------- Disposal Field: Distance from nearest well _. AhLtDistance from foundation__ 6).v- _-Distance to nearest lot line___. Number of lines�__________�____ Length of,aeach line_��___:: ______- Width of trench_____ _______________ ::- ------ !I Type-of filter material____. _ ___ epth of filter material________-__-___Total length-------,� __- _-- -- Seepage Pifi: �istance fo nearest wel!_______ _ _____ Distance fr m f undo+ion___-_ __ Distance to nearest lot line � t .'Number of pits------- -/----------Lining material___ .-Size: Diameter._._ --5- - ---- th ._ - -DeP _ Cesspool: Dis4nce from nearest well-----------------Distance from foundation------------------- material----------------------------------- fi ❑ Size: Diameter-- - ------------Depth----------------------------------------------------Liquid Capacity--. ----------------------gals. F Privy: ,{Distance from nearest well_._ -Distance from nearest building--------- -____---_-. \� ❑ k yDistance to nearest lot line___.'_ .,� /o Remodeling an_d/or repairing (describe)-------------- •:-----------------.-------------••---------------------- I € i ----- ----•- --------------- -------------•--------------------------------•----------------_----------------------------------------------------------------------- - s; -------------------------------------- --------------------------------------------' ' ' 1 : Y --- -- 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)----: ` �� ---------------------------------------------------------------------- (Owner and or Contractor) �r -----------------------------------------------------------------(Title)-------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- I----------------- -- -------- ------------------------------------------------ DATE--------- �' REVIEWED BY. ) - -- - - ----------- ------------------------------------------- ---- DATE---------I---- -------- - UILDIN PERMIT ISSUED ------- --- --L---------=-------- ----- ----------------------------------------------------------- DATE Altera ions nd/or res m ndations:-'-- --------- ---------------------- Altera --------- - - --- I _ __ _ _ ti� = - ---------------------- ---------------. -------- -------------------- FINAL INSPECTION BY:--- - - ---- ---' ------ --- ------ - Date------- pK1__--�f?-` ------------ - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.Co.