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APPLICATION FOR SANITATION PERMIT Permit No. .. ..... (Complete in Duplicate) f Date Issued .q��-----��--D- This Permit Ex ires 1 Year From 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. 1_�_7 JOB ADDRESS AND LOCATION.--- 1[ l-4 ' _li t _ - .__ "- -------- Owner's ----Owner s Name- ----- 04JdbXi4 *__1*&1�'�-'-=----------------------------- --------------- - ------------------------------------------- Phone.----- ------ --- 1102 ' --------------•--------------------------•----------------------------- ... Address--------------------•---------------------------------------- ---- Contractor's Name----------- - r --------•---------------------------------------- ------- --------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - ___ Number of bedrooms __3- Number of baths Lot size ------------------------.------- Water Supply: Public system ❑ Community system DE Private ❑ Depth to Water Table -----49ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobes] Hardpan ❑ Previous Application Made: Yes ❑ No [k 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---9x--------Distance from foundation-------1:-0*----Material__�+�__it-lok------------------------ No. of compartments---i�- ------------------Size._��---�_._4�'---------Liquid depth__..-.___-_-----___-_.Ca PacitY----- ,�* Disp sal Field: Distance from nearest !I_-. --------Distance from foundat' - Distance to nearest ne_______�/_______ ---- - _______________ Width of trench,,**--- �`'` of filter material__"—*— De th of filter materia #- Number of lines________________- __ _ _ _ Length of each line----- - -------Total length------------------------------------------- Type \ • Seepage Pit: Distance to nearest well1 I -- _1____._.__ ----------- t Number of pits.....' _------__Lining material_11POlk----------Size: Diameter----- 0---------Depth---- 5 --------------------- O Cesspool: Distance from nearest well-________________Distance from foundation--------------------Lining material-_.__________---------------------- ❑ Size: Diameter--------------------------------------Depth--------- ------------------------------------------Liquid Capacity----------------------------gal, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------.----___._________--_-_____..__---_. ❑ -------------------------- Distance to nearest lot Gne-------- ------------ - -----•-------------- -------------- ------------------- Remodeling and/or repairing (describe)------------------- ------------------------------ ---------------------------------•---------------------- ------------ --- ---- - --------- -------------------------------------------------------------------------- ------------- ______ - ------------ ------ -- - ------------------------------------ ------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with an Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------- -------------------•------------- `� =° i _ _�_y t i7[_ --- - ------ ------------ ------------------(Owner and/or Contractor) _1. ti .X _ Title - -------------- By:---------------------------------------------- (Plot plan, showing size of lot, location syste in relation to wells, bui gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY....�_�__-_ - __-- --- DATE-----9 —-------- ---- REVIEWED BY------------------------------------------ - -- ------------ ------------- ----------- -------------- ----------------- DATE--------------------_----------------------------------- BUILDING PERMIT ISSUED------------- •---------------------------------------------------------- DATE-------------- ---------------------------------------------- Alteratians and/or recommendations:__.__...________________________-__._--_--.-------------•--------------------------------------------------------------------------------------- ------------------------------------------- ------------- - ___` __d<------------------------- ----- - - ------------ ------ ---- -----------------------------------------------------------• - ....... ------ Date----------/—&- -°?y--�----- 1O- ---------------------- FINAL INSPECTION B� - ----•�--- =-- ------- 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 Rev,sed 8-'59 F,P,Co.