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APPLICATION FOR SANITATION PERMIT Permit No. .................... (complete in Duplicate) Date Issued This Permit Expires I Year From Date Issued ____ Application is hereby made to the San Joaquin Local Health District for a permit to cons'Yuct Vnr,,,tll the work herein described. This application is made in compliance:with County Ordinance No. 549. JOB ADDRESS:,W'AND LO' CATIO — ----- ----------------------------------------------- -0-----,-6--L---,-------------------L---i-- ------X------,- --- -:----•- Owner's Name Phone------- --- Address---------1K_T - -I Contractor's Name- - --------- --------------------- Phone___ N-I---_-f-4-------_-[--_-6--------- ----- V Installation will serve: Residence El Apartment House E] Commercial E] Trailer Courf)lf Motel ❑ Other ❑ Number of living nits:_ nifs:_ Number of bedrooms ---------Number'of baths _*_ Lot size ___:________$__ ________________ Water Supply: Public system (] Community system [] Private 171 Depth to Wafer Table 4Q ft. Character of soil to a depth of 3 feet- Sand E] Gravel E] Sandy Loam El Clay Loam I] Clay ] Adobe [3 Hardpan 0' Previous Application Made'l Yes t No y New Construction: Yes 0 No Ly PHA/VA: Yes 0 No El TYPE OF -INSTALLATION AND SPECIFICATIONS (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) S e p f ic,,T a n k: Distance/from nearest well-----------------Di4incbJrom foundation-------------------Material------------------------------------- ----------- No. of compartmenfs--------------------------Size_-___-_`=------------------:_._Liquid depth-------------------------.Capacity-------------------- - Disposal" apacity------------------------ Disposal' Field: Disfance,from nearest well-----------------Distance from foundation.-------------------Distance to nearest lot line.-_..- -.--_____- ❑ Number-6f lines------------------------- ----Length—o- f each line--------------------------_--.Width of trench------------------------------------ Type of iter material-------- ------Depth of filter material----------------------Total length------------------------------------------ Se e Pit: Distance to nearest well------ 21YO'. D i s t a_n'ce- f f 10 clation----J-4-----Distance to nearest lot line__...__.__ Number of pits--------I------------Lining material__ ----- -- - ---Size: Diameter__-___- _ ____.Depth------ --------------- y , % / Cesspool: Distance from nea're�f—well_`-�istan�ce from foundation....................Linin material-f-----�r------------------------------- -ze. Diameter-----------------------------_, e k El S1 -------- --------------------- D pfhf---------------------------------------------------Liquid Capacity-�------I-----------------gals. Privy: Disfance from nearest-well__________________________- _.______-_.:.._Distance from nearest building-.- -_- - Distance to nearest lot line- - ---------------------------- F1 ----------f--------------------------------------------------------------------------------------- ,ww_paw� Remodeling amel�qp- ----------- ....... ------- ------ ------------ --------------------------•----•------•----------------- -- - --- - -- - ------------------------------------------------------------------------- ---------- ------ ------------------------------ ------------------------------------------------------------------7�----------------------- -- --- -------------------------------- - •-------------------------------------------------------------------------------------- I ----------------------------------- ---------------------------- ------- ----I----------------------------- ---------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this aplPric-ation•—a'nd that the work will be done in accordance with SanJoaquin County ordinances, State laws, and rules and 'regulations of the Sa'� J-�aquin.Local Health District. ti (Signed)-- - -------- ------ Z;---- -------- Contractor] buildings, etc., can be placed on reverse side). -------4_�_ __zw4 (4 --------- -------- ---,[-(Titlle)----------------------------------- ---- ----------------------- (Plot - -(Plot plan, showing size of lot, loca+ion'of system in r lation to wells, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- DATE----` .............e'.7 e__0---------------- --- ----------------------------------------------- REVIEWEDBY----- ---------------------------------- ---- -------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------ ----------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:--,------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- -- ------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- --- ----------------------------------------------------------------:---------------------- I , A -A ---------------------- ------- ------------------------------------------------------------------------------- ------------------------------------ ------------------------------- ------------------------------------- . - f I I, F ; . I .................................... ..... ......... ------------------------------------ ------- -------------------------- ------------------ --------------------------------- -- ---- I-------------------- D 6d 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 Lodi, California Manteca, California Tracy, California FS-9-2m Revised 8.'59 F.P.Co.