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0� 11_�4f33d/ �1 APPLICATION FOR SANITATION PERMIT Permit No. ..�......�.........:,� f� li D l C ( ompete in Duplicate) Date Issued ----------------5...� t1 This Permit Expires 1 Year From Date Issued U Application is hereby made�lfo 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. + I / - - ------•--•--------------}--.- JOB ADDRESS AND LOCATION..._..., -,ll -- :�-cL�--. --------------------------------- ----- -- -- -� Owner's Name---------- ` r ------ -------------------------------- - ----------------------------------------- Phone- /"fes- _Q s_-/...---- Address_.-_----- -, 14....AA----- mss Contractor's Name--------- �-x -R� _. 4- -t---------------------------------- ---------------- PhoneA-t— _..3 Qr L' Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: ___ _- Number of bedrooms __X_ Number of baths ---/--- Lot size ____-�!-` .- a_ ---------------------------- Wafer Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table --------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made:ll Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ I, 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-----------------Distance from foundation--------------------Material________.-------________________________..______- ❑ No. of compartments---------- ------ - ------Size--------------------------------Liquid depth--------------- ---------Capacity--•--------------f---- } Di s os I Fi d• Distance from nearest well--Distance from foundation_ -- _`'`.Distance to nearest lot�ine____*..... . p --- �----;-;,s tit �: , lit Number of lines----------/._ �_ __Depth Length of each line________ _____*__ __:Wid'th of trench __. - - - .--•------------------ Type of filter material____ _ of filter material--- f Total:length___________________________________ Seepage Pit: Distance to nearest well___ stance, fr m 'foun anon= G __._.._,_bist�nce t arest lot line._ _._. _:.. . Number of pits_�.____�_________Lining material__ ___ Size.Diameter__-- _�x �epth__c _______________ IN Cesspool: Distance from nearest well________________Distance from tfoundation.----_--------------Lining material__._._____________________._-_.._-__. ❑ Size: Diameter ----------------------------------Depth--------------)------------------------ LiquidCapaci#Y gals. Privy: Distance from nearest well-------------_------------------------------'. `°Distance or m nearest building ❑ Distance to newest lot line---------- ---------------------------------------------- Remodelingand/or repairing fdes, Jibe):-------------------------------------------------•--•-------------------------•-------------•---------------------------•--•-------------------- --------------•------------------------------- ----------------------- -------------------------------------------------------------------------------------- ----------------- - --------- -- -------------- -- ----- ----------------------------------------------------------------------------------------------------�-------------------------•-------------------- - --------- I hereby certify that I'jhave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules �nd regulations of the San Joaquin Local Health District., (Signed) -------- --€ (Owner and/or Contractor) i � - ----------------------------- (Title) - BY� - ----- { ) { (Plot plan, showing size of lot, location of system in relation to wells, buildings etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- --- -- ------------- -- -------------------------------------- DATE----- ----------- --------- REVIEWEDBY_ �f--------------------------- --- - -- -------------------------------------------- DATE --- -�-------------------------•- BUILDING PERMIT ISSUED--------------------------- -------- q --- ----------------------------------------------------------- DATE------------------------------------------------------------ 1 11 Alterationsand/or recommendations:------- ------ ------------------ --------------------------=----------•-----•------------•------------------------•--------------------------------------- r ------------I''----•-•-----'------------------ -------------------=----------------------------------------------- ----------- -------------------------------- --• -------------•-------•- 11 -II P YII ----------------- ---------- -.-------------------------------•-------------------------------•----------------- -------- ----•----------------- + --------- q�_ °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 i! Lodi, California Manteca, California Tracy, California ES-92M Revised 8-'59 F.P.C.. .�