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APPLICATION FOR SANITATION PERMIT Permit No. .._1�_�._�_Z (Complete in Duplicate) /� � Date Issued _____.1..�>�_f��` 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 LOCATION1'- _--- ------------------------- Owner's -------------------- Owner s Name ' .-- '1-�� f� ------ - Phone------------------------------ (J` Address-------------<;V - --- ----------- --• ------------------------ r Contractor's Name______________ _ _ _____ F. Phone ; - � - _ __ � Installation will serve: Residence Apartment House ❑ Commercial [:] Trailer Court [3 Motel [jOther ❑ Number of living units: .__%:N- of bedrooms --_ Number of baths _/_- Lot size_________ ~ S ---------- Water Supply: Public system J Community system ❑ Private ❑" Depth to'Water Table 49-50 ft:'- Character of soil to a depth of 3 feet: Sand Q Gravel [] Sandy Loam [-] Clay Loam ❑ Clay (] Adobe(�J` Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes ❑ N0 FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIE CATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sep ank: • Distance from nearest welt_______________Distance from foundation--------------------Materiai--------------------------------------{-________- /J(5T4✓� No. of compartments---------------- {Size--------------------------------Liquid dept'n--------------------------Capacity---- ----------------- Disposal Field: Distance from nearest well_ - VA14�-Distance from foundation_/�_________-:Distance to nearest lot lineZ�_.______ �6 �10TIO'y Number of lines_________ __ ____________Length of each line___„ s _: � __ Width of trench_____._��____ __------____ Type of filter material_: E! � :Depth of filter)mafierial__/-�--__'s__.Total, length__ c ________________7 See a e Pit: Dista_n e'to nearest well_" � .__ _Distance'. om foundation___ _ - a� __-.Distancerto nearest lot lin{�.d_____:_ Number of pits----- :________Lining material _-Size: Diameter'-_, _ ______-Depth__-�j------ - _ _ r-, Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------------------- F1 Size: Diameter-,--- ----------- -------------------Depth--------------------- ----------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------- --Distance from nearest building------------------------------------------ t , ❑ Distance to nearest lot line_________________________ •• - - "�l -------�------------ =_--=---------- ---------- lin and/or re a;rin describe :,___- 1_______ --------- - - � 4 ir .�-ter 11 4 S - _ _ __ _ [ ------------•--------------------- ---•---------- ------------------------------ -- - ---------------------------•---------- ------------------ I hereby certify tYmt I have preps ed this'applicafi d•that the work will-be done in accordance with San Joaquin uin Count ordinances, State laws, and rules egula tons of a Joaquin Local Health District. 1 (Signed) c r --- ------- _ _-- and/or Contractor) --------------------- - ---- a -----------------=---------------------` - Title ---------- it _ �- caner B (Title) Y• = - --- - ---- -------- --- ---- (Plot plan, showing size of lot, location of system in relation to wells,"buildings, , can be placed on reverse side). f FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY_ ------ x----- 11---------------------------- DATE-V----------------- REVIEWED BY — = = -----------------------• DATE__ = = BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------t%------------------------------------------------ Alterations and/or recommendations:------------_--------------------- { S _-___-_________________________________________--------------------------------------------------------------------------------------------------------------------------------------------------------------.,...--_-_________- _________________________________----_______________-________--__-______._________-__.___________-__________--__-_________________.-_-_---_-__-_--____-_______________________-__-__________________________ ------------ ----------------------------------- ------------- ------------------------------------------------------:---------------------------------------------- -------------------------------------- ___ _________________________________________________________ ___________________________________________________________________________________________________________________________________________________ _______________ - Date FINAL INSPECTION BY:.---------- -- ---' - _ : - I SAN JOAQUIN LOCAL HEALTH DISTRICT f 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.