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,2 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued .-__ ).:n... 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 AN OCATION- ,- ---- " -------------------------------------------- -------- Owner's Name--------------- -------� -•---..... ---..... •---• -----•----------------------- ------ Phone. .--••----- •..-- ........... Address-- ,�� _ / Q' . --------�--- ------------- --------------------------(-------------- -- ---------------------------------------•----------- Contractor's Name.......-- - ------------------------------------------------------ -•-----•------------------ Phone................................... --------------------- - Installation will serve: Resident � Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- of bedrooms_:°Number of-baths ---/--- Lot size __ _.. hi__Q_________________________________ Water Supply: Public system ❑ Community system � Private ❑ Depth to Water Table � ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay X Adobe ❑ Hardpan ❑ Previous Application Made: Yes No ❑ New Construction: Ye�es��No ❑ FHA/VA: Yes ❑ Noy TYPE OF IN, AND SPECIFICATIONS: ��•ai (No septic tank or cesspool permitted if public e r is available within 200 feet.) Septic T n c� Distance from nearest well ___ .____- _. s.ance from foundation--------------------Material-------------------------........................ No. of compartments ize Liquid depth Capacity Disposal#Fi Distance from nea st well-________ __-_ istance from foundation._�__�_____-Distance to nearest lot I'ne__S:___... �� N er of lines__•�7-----____ •�- -�_"_�__,,Length of each line_�Q__'.jZ.L�_-_�_I�-Width of trench_____.__-_________________________ of filter material_ I `%pepth of filter material-----��{_I_-_______Total length-____1.O__�!_________________________ �Me ge it: Distance to nearest well_-______..___-_____Distance from foundafion....................Distance to nearest lot line_.._._-.-__---_-- ❑ Number of pits______________________Lining material-----------------------Size: Diameter------------.----------Depth--------------------------------- Cesspool: Distance from nearest well------------_----Distance from foundation--------------------Lining material________-_______________-.__.___-_ 'i ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 1-1 Distance to nearest lot line.-------------------------------------------------------------------------------------------------------------------------------------------- r., Remodeling and/or repairing (describe) ---------------------------------------------••-------------- ------------------------------------------------------.-------------------- ��V -------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- -------------- --------------------- ---- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance wifih San Joaquin County ordinances, State laws; and rules and regulations of the San Joaquin Local Health District. (Signed) A_ ........__ t ------------------------ ____-_(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 APPLICATIONACCEPTED BY------------------------------------------------------------------------------------------------ DATE----------------------------------------------------------- REVIEWED BY------------------------------------------------------------------------------------------------------------------------------ DATE-------- ----------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE.---------------------------------------------------------- Alterations and/or recommendations-------------- - -- -- ------------------------------------------------------------------------------------------------ ----------------------------------- ------------------------------ -- ----- ---- - - - ... - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------- �- - ------------------------------------------------------------------------ ---------- ----- --- -------------- ---------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY------------------- ------------------------------------------ ------------------ k 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-9-2M Revised 8-'59 F.P.Co.