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r f APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Expires i Year From Date Issued Date Issued -------- e-d- 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. / - lL'JOB ADDRESS AND LOCATIO ...-- - Phone--- Owner's Name---•--------- ------ _ ---- Address----------------. ---------- Contractor's --------------------------------------- i Name-------------------------•-----.. ... _ - ------------------ Phone----------------------_-------•-- -installation will serve: Residence partment House ❑ Commercial E] Trailer Court [:1 Motel E] Other E]tNumbe'r-of living units: _/--- Number of bedrooms _- Number of baths /• Lot size ---Ir-20-'x----1--q-.---:--/•------ f Water Supply: Public system ❑ Community system ❑ Private '-Depth to Water Table ........ ft. 4F I. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe HarclNn ❑ .� r Previous Application Made: Yes ❑ No Cg- New Construction: Yes No ❑ FHA/VA: Yes ❑ No� ~TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public wer is available within 200 feet.) , Septic Tank: Distance from nearest well--- -Q__.__Distance from ndation--.-/r--_--___.Materia e - 4___ ;_ No. of compartments.---------02.._____-.--Size..— 4t --�iquid depth----.-.-----�------.----CapautY--•------�r�l�Q Disposal Field: Distance from nearest well ---Distance from"found ion.-.-__TG._ Qistance to nearest lot line_____ -------- 4t _______ ' Number of lines_____________ _____- ._---Length of each lin a� _ ------Width of trench______.__;_�__________.__� 4' Type of filter material__-'.__Depth of filter material- Seepage, Seepage Pit: Distance to nearest well_ ----------------- from foundation----.---------------Distance to nearest lot line--------.--.--_.- ❑ Number of pits----------------------Lining material-------------------:.---Size: Diameter-----------------------Depth-----.---.-.--------------------- 4 G Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material------------------------------------- l [] Size: Diameter. Depth----------------------------------- ---------------Liquid Capacity------------------ -------gals. �1 a Privy: Distance from nearest well_,-ry__________---------------------------------:_Distance from nearest building-------.--._-----__-.--___-..- a ❑ Distance to nearest lot line------ ---------------------------- ---------------------------- ------------------------------------------- -------- -------- Remodelingand/or repairing Idescribe-------------------:---------------------------------•--------------------------------------------------------------------------•----------------------- __ Y y _ ________________________________________________________________________________._.___________.______._.__._....____________._______________.__.__.._____.________._________________-__________________._______._______.. @ i ---------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.-_----.._-_.-_.--.-_.- 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 ru and regulations of the San Joaquin Local Health District. i` ....,,,..rte.... ) ` (Owner and/or Contractor) -------------- --_- - ------ By:------ ----B '---------------------------------------------------•------------------------------------- ---=------------------------------------(Title)----------------------------------------- - - -- -------------- (Plot plan, showing size of loft, location of system in relation to wells, buildings, etc., can be placed on reverse side). FORD ARz T USE ONLY APPLICATIONACCEPTED BY-- - --- ---------------- ---------- ------ ---- - --------................ •-------------,DATE--- �---- ---------- ------------------------ REVIEWEDBY----------------------------------------- --- -------------------------------------------- ------DATE------------•-------•- ------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------- ---------------- DATE-------------------------------------------- --------------- Alterationsand/or recommendations----------- ---------------------------------- -------•---------------------------•-------------------•-------•----------------------------------------------- ' -------------- -- ------------------------••------------- -- >!2 . ' Z�i - -- I/ V-- - -- ------------------ ------_�- ------------ - ---- -- ------ - FINAL INSPECTION BY- .- SAN . Date_. / r 5 / k SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streot 132 Sycamore Street 914 North "C" Street I Stockton, California Lodi, California Manteca, California Tracy, California -ES'9-2M Revised 8-'59 F.P-Co.