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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) " This Permit Expires 1 Year From Date Issued Date Issued ___________________ Application is hereby made to the San Joaquin Local Healfh 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 A OCATION... 7 ___dfJ- --- � POwner's Name--- ---------- - - ------------------------ Phone--------------------•------------- ;w Ap . 'Address--------------- -----=-------------------------------- ---------------------------------------------- Contractor's Name tPhone_ Installation will serve: Residence-12�_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:._____ Number of bedrooms __ Number of baths _______ Lot size _-_---/ ..__�___1--70_____________ Water Supply: Public systemf't!�_Community system ❑ Private ❑ Depth to Water Table _ ____ ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan Ej Previous Application Made: Yes ❑ No 2�_ New Construction: Yes ❑ No- E]Yes ❑ No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �'ca Distance from nearest well-________________Distance from foundation--------------------Material _____________.___.______..._______----.---.__._. No. of compartments-------------------- -----Size---------------•----------------Liquid depth------------- -----------Capacity----------------------- osal i9d. Distance from nearest well--- from foundatiDistance to nearest lot line____P-_�--_- �aL Number of lines_____-,l_________________________Length of each line_`__ -- -A�_____.Width of trench_��/�_..__._________ Depth of filter material---___- _ ___.Total length ��'___5p__------------- C Type of filter mater�al_1�i_p_ (________- p ��//-�-,,---- 9 // �' Seepage Pit: Distance to Weare twell_- )-'_`-`-.__-_Distance from foundation__` _r____..D' tance,to nearest lot line------Com..------ Number of pits_________________Lining material___r��___ '.______-Size: Diameter____-----------------------Depth_ ____________._ i y _ Cesspool: .Distance ;from nearest well-----------------Distance from foundation--------------------Lining material...___..__.___-____.______._________ ❑ Size: Diameter--------------------------------------Depth --------------------------- - - ------------_._Li quid Capacity----------------•-----------9als. I Privy: Distance from nearest well-------------_____-------------------------------Distance from nearest building-----______________________..__..__-___. ❑ Distance to nearest lot line---------------------------- - ---------------------------------------- ----------------------------------------------------------------- --- Remodeling and/or repairing (describe): --- ---------------- --------------••------------- ----------------------------------•------------- I — ------------ ------------------------------------- ---- -- --- -- -----•---- - = i F: I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat .laws, and rules and regulations of the San Joaquin Local Health District. u Si ned5 % �. /� /17s -� U� Z ------------------------------------------ Contractor) 9 } --------- -- - B - ----------- -------------(Title)------ ------------ ----- ........ --------- ' ! (Plot plan, showing size of lot, location of system in relation wells, buildings etc., can be placed on reverse side).• I FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY____ y `------------------------------------------------------------------ DATE---------1& 3-4,-7--------------------- � 5 -_ . _ .�. _ REVIEWEDBY------------------------------------------- - -------------------------------------------------------------------------------- DATE---------------------------------------------------------- BUILDING PERMIT ISSUED--I -------------- ------------------------------------------------------------- DATE Alterations and/or recommendations: fi — �� ---•--------------------------------------------------------------------------------------------------------------------- -- ------ --------------------------------- - -- ---- -- ------------------ - -- -- - ------------- ------------------------------ FINAL`( TION B Date-----------(-)- �--- 6p------------------------- 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-92M Revised 8-'59 F.P.Co. � - I