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APPLICATION FOR SANITATION PERMIT Permit No. . ` (Complete in Duplicate) _ -- This Permit Ex fres 1 Year From Date Issued Date Issued --------- ------------11 7 . Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, This Opplication is made in compliance with County Ordinance No. 5 9. _. 4—e-t JOB��ADIDRESS AND LOCATION t ------------- -•--- Owner's Name------- - a :` - i � - ---------- ------ Phone.._.-"----- Address_. _ - .-- -- �------------------ -- ---- ---- --- �.-- -------------- Contractor's Name_____ ___________-- ^� ----------------- ---- -- ------------•----- Phone. Installation will serve: . Residence,- Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -----UNumber of bedrooms�µ. Number of baths _t Lot size __-_-_/f- -x- 2O Water Supply: Public system pP Y= y ❑ Community system Q Private, Depth to Water Table -------- ft. Character of soil toa'depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobejff, Hardpan ❑ Previous Application Made: Yes ❑ No j =New Construction: Yes ❑ No)R, FHA/VA: Yes �< No TYPE OF INSTALLATION AND SPECIFICATIONS: E] (No septic tank or cesspool permitted if'public sewer is available within 200 feet.) 1 f §- Septic Tank: Distance from nearest well 1-- ---Distant from-foundation---- �'�1 No, of compartments--------` ------ ----- --Size depth_--------�--__------Capacity-- �� C7------ Disposal Field: Distance from nearest well----!> ._Distance from foundation--____�C_:---Distance to nearest lot ine-__+ Number of lines--------------/------ -- Len th of each line_-------__---- -- ' Q":__.Width of trench- ":",_--_ Type of filter material._ De ,fih of fiifier mat erial___-______G _--_Total length_----------------- Seepages V Distance to nearest well-____--,t7a--__Distance from foundation-----/C_......Distance-to nearest lot fin 141 Number of ___-___ /-__-.--�--Lining material___�7.•�.��ize: Diameter__._._ _ `�� ` �C C ----Depth--'----------�-------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material------------------------ L4 ElSi!e:Diameter----}--------------- ----------------Depth---------------------- -------- Liquid Ca--------------Li aci q p ty ---_----__ ------- Privy: Distance from nearest well--_-."-__---------------------------------------Distance from nearest buildin 1771 g ; -._ .. Distance to nearest lot line-_..__.. --------- --------- x Remq�eling a /or re iring (des ihe):--- t ------- ---- - ------------s-^----- -------- -� ' ��-- --- qL -- -------- -----1-1 lam ` ! - 1 � i ---------------------------- ----------------------•----------------------------_•------------------------------------------------------------------ --------------------11-------------------------------------.. I herebycertify that I have - Y prepared this application and that the work will be done in accordance with San Joaquin County ordinances, f to laws, a and regulations of the San Joaquin Local Health District. (Signed) { a --------------------------------------------------------------------------•-------------------------------•----------- -------(Owner and/or Contractor) '9---------•-------- 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE.ONLY APPLICATION ACCEPTED BY___________ ________ __ " -__ ...� --- DATE--------Y _ - - 4-7----------------- - -- DATE----- -------` BUILDING PERMIT ISSUED _--#_------_-_- Aterations and/or re4commendations:___,_____ --""""- -- -`---- ----------------------------- ---- --------------------- - ------ -----------------•--- --- --- ------•- - --- --------------------------------------------------------------------- FINAL INSPECTION BY: Datex-------- ------------ ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 7 130 So`ufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Tom'- Stockton, California Lodi, California Manteca, California s Tracy, California ES-9-2M Revised 8-'59 F.F.Co.