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fo �f .1)�APPLICATION FOR SANITATION PERMIT Permit No. ..I� - C1� J (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued l ---- --_- Application is ereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. s application is made in compliance with County Ordinance No. 549. j O3 0-0/ JSB�AD�RESS AND LOCATIc, � �/1s� __ - - - -----------.------- Owner's Name----.-___ _ __t_-.__ �� - ---------- ------•------------------------------ - ------------•--- - ------ Phone-----•----------- - Address------------- - • -----------------•------------------------------------------- •-• _ ---•-- ------------------------------------ Contractor's Name--------- -------- -- — ------------ Phone----------------------------------- ------------ - - r Installation will serve: Residence Apartment House-�❑ Commercial ❑ Trailer Court ❑ Motel [I Other ❑ Number of living units: :_ -Number of bedrooms __ Number'o£ baths/ Z Lot size ___ Water Supply: . Public system ❑ Community system E] Private �epth'''to Water Table ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E] Previous Application Made: Yes ❑ No New Construction: Yes 9?'Ao ❑ PHA/VA: Yes L,--No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if publiesewer is available within 200 feet.) Septic Tank: Distance from nearest well -- -Distance from foundation__- ' ,. --------.Material---��- -- - - - ----- No. of compartments________ ' Size__ :- 9 per - -----------Capacity.____ _ -- •--- ---- 1�_° -- - --Li uid de th---- -- Disposal Field: Distance from nearest viell__y. Distance from foundation____�P__"--___Distance to nearest lot line---,4r ! ®� Number of lines----------- --------'-'--,_-- :Length of each line---------- Q-4 �/ YP --- Width of trench- ' ----------------------- '1 Type of filter material_�� _ --�-------De Depth of filter material_--- �� bi to ce o •---- -�----------------•---�-,- I Seepage Pit: Distance to nearest well_lee - Distance fr m foundation___ T°fial length � � -------- nearest lot line__________._ [/ Number of pits-----�-------->____Lining material__ __, - .e_._Size: Diameter___ i! Dep thf Cesspool: Distance from nearest well-----------------__Distance from foundation------------_-------Lining material---_------------------------------- __. d ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. . Privy: Distance from nearest well----------_c:-____- __________________Distance from nearest building fw -.. _ n g--------------------•-------------------- ❑ Distance to nearest lot line - -------------------- - ------- Distance - - - ----------------------- L ----------------------------- Remodeling and/or repairing (describo):____---- ��` y ;;::; .. -- - ---------------- ---------•----------•----------------- ------------------------------- --------------------------------- ------------------------------------------------------------ _-------------------------------------------- ------------- ---------_---------------_---------------------- I hereby certify that I have prepared this application and that the..work will be done.in.acc_ordanco with San Joaquin County ordinances, State laws, and rules d regulations San Joaquin Local Health District. i � (Signed)---------------------;-- ------------ Contractor) By:---------------•--------•-------------_ - .. ------- 4 --------------------(Title)----- J j ------- - - ------ ---- I (Plot plan, showing size of lot, location of-system in tion to wells, buildings, etc., can be placed on reverse side). i FOR DEPA _MEW USE ONLY APPLICATION ACCEPTED BY--------- -- --------------------- -------------------- DATE------ r .� -�----------- REVIEWED BY ----------- ----- ---------- •---------------- --- DATE------ ----------------------------------------------------- BUIL DIN PERMIT ISSUED------------- =_=---__ -- - ---- DATE----- --._ -- --- -- _-.... _ ----------------- --------------------------- - -- ------------------------- Alterations and/or recommenda+ions:s____________________ .r --------- ----------------- - -------- -------------------------------- ------------------------ ------------- -------•---•--------------------------------- ----------•----------------------------------------------------- ----- FINAL INSPECTION `= ------ Date----- 1 :::'- #1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American St r et'�.. 300 Wes+ Qak $f aef Aid 132-5 cemors Sfree+ A Y _ 814 North "C" Street Stockton, California Lodi, CaliforniaManteca, California Tracy, California a ES-9-2M Revised 8-'59 F.P.Co.