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tf APPLICATION FOR SANITATION PERMIT Permit No. ,3cJ. (Complete in Duplicate) s 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 This AND L CATION. - f-- ---- - '-- -- 'A----------- Owner's Name---------- !� ----------------------1------------- --------------- - ----------- - hone _ Address------'------------ - -- ... Contractor's Name `' r.. Titl -- ---------- Phone------------------------- . will serve: Residence [g—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---1._ Number of bedrooms .S_ Number of baths __Z Lot size _ __ / _ _--_______________________ # i Water Supply: Public system ❑ Community system ❑ Private F�rDepth-to Water Table _*XfTt. Character of soil to a depth of 3 feet. Sand Gravel Sand Loam i P ❑ ❑ y lay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No P4`� New Construction: Yes ❑ No [g'PHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) &ef Ta 4'--Dispos nk: Distance from nearest well_________________Distance from foundation______________-____.Material____ ___________________________-___ ___________No. of compartments---------- ---------------Size-----------------------•--------Liquid depth--------------------------Capacity---•------------------- I ield: Distance from nearest well-----------------Distance from foundation-------------------- Distance to nearest lot line----------------- 1 r i Number of lines-----------------------------------Length of each line---------'------.-------------Width of french----------------------------------- Type of filter material---------I______________Depth of filter material______=_______________Total length______________-__-_.___________-_______ i /� � t Seepage Pit: Distance to nearest well..AfP-----:--Distance rom undation__f _�____--D�is ante to nearest lot line---- i ®� Number of pits______ ____________Uning material ___- Size: Diameter_,? _ _______Depth__.'_ __4�..__�___ r Cesspool: Distance from nearest well_________________Distance from foundation_____`_----------- Lining material---------------------------------- ❑ Size: Diameter-----------------'--------'------ ----Depth------------------------------ ---------------------Liquid Capacity----------- .-------gals. F Privy: Distance from nearest well-____________________________ ____._.._Distance from nearest building______.___._________-_-________________._. ❑ Distance to nearest lot line ---------------------------- i., Remodeling and/or repairing (describe):-------------- ___________________________________________________________________ g _ ----_--------------------------------_______ i y' i _________________________________________________________________ ____________________________________________.___________-_________________-__-___________________________________________--_-_______________________...___... .\.t. 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)------ ------- --------------------------------------------------------------- actor) By------------- - ------•------------ / ------------------------------(Title)— ;Plot plan, showing size of lot, locatio system in relation to wells, buildings, etc:, can be placed on rever si �_.. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--'t... ---------------- ---------------------------------------- DATE-'-D6".REVIEWED BY----------------------------- DATE--- - - ------------------------------ - ----------------------------- - - ------ { 12 BUILDING PERMIT ISSUED-------- ------------------------------------------------------- DATE------- Alterations and/or recommendations--------------- -------------------------------------------------------------------•--------------------- -•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------- -- FINAL INSPECTION BY --------------------- Date---------- ----------------------- 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 ES-9-2M ' 'Revised 1.57 F.P.CO. �t /