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n /�I APPLICATION FOR SANITATION PERMIT Permit No. ..I,-L)0.-j_ F {Complete in Duplicate} l This Permit Expires I Year From Date Issued Date Issued `r 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. 54 JOB ADDRESS AND LOCA Sl/+ Owner's Name_ ! r ` ---- -------------------= ----- ----------------- ---------- Phone 41. Address_____________! . --------••-------------------- --------•--------------- --- -- Contractor's Name----- Phone -- - - - -- - -------------- Installation will serve: Residence RRI"�Aparfinent House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/_._ Number of bedrooms --/-- Number of baths _/---- Lot size _ .' -.- -� Water Supply: Publicasystem Community system ❑ Private ❑ Depth to Water Table ;/',,"Od ft. Character of soil to a depth of 3 eet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �ardpan ❑ ' Previous Application'Made: Yes [],''No ® New Construction: Yes ❑ No 2?-`rHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool! ermi#ed if public-sewer is-available-within 200 feet:); Septic Tank: Distance from ,ne,arest well---- "---_Distance from foundation_.AQ---------Mater�l__<neares No. of compartments---------_ S¢e___ ,,��{-� /'" ' b►r Liquid depth .` - city- e �--•-- Disposal F" Id: Distance from;nearest well-_. -r-- Distance from foundation____-/ _�_---Distance ------•--- Number of lines-------•-,�----�- --- -__--- Length of each €ine___�11�-___-_:-------Width of trench------.�'��.------_-- ti ---- Type of filter material_ +�/ Depth of filter material-- 1-110Y7 -----Total length________*_i9_/--------------------- l Seepsa P'#: Distance to nearest well______" __---Distanoetion,____14----___.Distance to nearest lot line__-u' ----------Number of pits___ f____-_____--Lining materiaize: Diameter__--,, 3 De th____ ao�� „-P vS+�/-------------- Cesspool: Distance from'nearest well_________________Distantion-.-_____.`-__ Lining material___-___ ____-_-__-.-__- ---- ❑ Size: Diameter_______________ Depth” t Liquid Capacity ----------gals. Privy: Distance from nearest well-------------------------------------------------Distance from`,nearesf building ❑ Distance to nearest�Iot line----.----------------------------- -- - Remodeling and/or repairing (describe):__-_-_--___-�fe�_ ,f7 a - -=j ` -------------------------------- ------------------------------------------------------------------------------------------------------------------------------------4------------------------------------------------------------------------ ------------------------------------------------------------------------------- �. i ------------------------------------------------------- `E ------------------------------- -_– I hereby certify that._I have prepared this application and that the work will be done in accordance with San Joaquin County .,ordinances,-State laws, and° ales and regulations of the San Joaquin Local Health District. (Signed)_ ... (� Contractor) - ------------------------------------ 0- W_ _ By:-----------------------------• - ------ ---- Title (Plot plan, showing size of lot, location s+em'rin:.relation to wells, buildings, etc., can be placed on reverse side). FOR EPAkTM NT USE ONLY APPLICATION ACCEPTED BY__-_-__ __-_____ ------------- DATE---•-- �P• �°a c REVIEWED BY DATE ............ -------- ------------------------------ ------------- PERMIT ISSUED •----------------------- ----------- DATE t Alterations and/or recommendations: ________________ ---------------- --- ----------T --- -•--- � - _ ---------------- ----- ---- - - - --- ----- ---- FINAL INSPECTION $ / --- - ---------- Date--- SAN ate--SAN JOAQUIN LOCA_ L HEALTH DISTRICT 130 South American Street 300 West 68k'•S#set.' i � �, 4 ;132 Sycamore Street., 814 Norah "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P,Co.