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APPLICATION FOR SANITATION PERMIT Permit No. _1t_D_-_Y_I-__---_ (Complete in Duplicate) - - Date Issued ._-'__y�/J_._� 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 ADDRESS AND LOCATION-----_____- ---------- -----------------------:----------- ------ Owner's Name-----/~- -•--- ------------------------------------------------------------------- Phone------------------------------------- ' Address----------------- -—--------3G ... --`-r ---,q--..�"-------------a---- - - Contractor's --------------- --------------------------------------------------------------------------------- ---------------- Phone-------- ---------------------- Installation will serve: i Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Nurnber of living units: J---- Number of bedrooms __�- Number of baths _ Lot size _____�_?9�'__72J _______________ Water Supply: Public system ❑ Community system ❑ Private KI Depth to Water Table yrft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam pp Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ a Previous Application Made: Yes E❑ No,R New Construction: Yes,�j 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 mares+ well--47P--------Distance from foundation-- 0- ---- Material--- No. of com artmenfs_____�.-_____-___ -----------------Liquid de th_!_'_-_______._._________Ca acit P!D d Disposal Field: Distance from nearest welLcg.a.--------Distance from foundaticn_f0-________.Distance to nearest lot line__.--__--__- Number of lines-.-_!�-------. Length of each ---.-.Width of trench____7_�� _______________ Type of filter material__-__*_-_ --Depth of filter material_If'________J_Tofal length__. _ __ _______x__._ Number of pits__________________Lining material '��'�{�- ___��___..Dista%certo nearest lot lin•,e�__ �-___;_h�� See a Pit: Distance to nearest w II---- -�Sw`--------Distance from foundation P - --- __Size: Diameter ---.Depth----- -- ------� .f�, r Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- -� ❑ Size: Diameter---------------------------------------Depth---------------------------------------------------Liquid Capacity-------------------- -------gals, fh Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____._______--_____-_--_______._________- i ❑ Distance to nearest lot line-- -'-- ------------------ --- ----=----------------------------------------------------------------------- ' Remodeling and/or repairing (describe):------=---------------------------------------------------------------------.-------------------------- ---------------------------------------------- -------------------------------- � -- -- ----------- ----- ---------------------------------------------------------------------------------------------•-----------•----- -------------------------------------------------------- I hereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and rules and regulati-ons of the9San Joaquin Local Health District. ` (Signed)-- ---- --- - --------- ----------= =-- ( / ) Owner and/or Contractor By:.............. - ------------------------- ----•----(Title)---------------------------- ----------------------------------- (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-2 A'/-- REVIEWED BY-------------------------- -------------------------=--'-------------------- DATE BUILDING PERMITISSUED------------------------------------------ ---------------------------------------------------------- DATE--------------------- Alterationsand/or recommendations:-------------------------------------------------•--------------------------------------------•-••---------•-----•-----------•-------------•----------------- --- -------- ------'-•-•-----•-----.... .. ..: .....T.------------------------, :...... ..._.... -•---....._..._........................__...--•-----------------.----- ------------------------- - -_ --- ` --' ------ --F------- ----- ------ --------------------------------------------- j •-------------------------------- --------------- ------------------------------------------------------•--------------------------I---------------------- ------------------------------------------------•------------ FINAL INSPECTION 'BY- -1 ".e ... ----------------------- Date....... L SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Stroet 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.