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APPLICATION FOR SANITATION PERMIT Permit No. .... �� (Complete in Duplicate) `l Date Issued .__.: This Permit Expires 1 Year From Date Issued Q 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 LOCATION--- _----------- Owner's Name--------aQ&--•--. ---------------------•-------•--------- ------ -------------------••--------------•--- Phone.................................... Address--- .� ��.... ---------------------------------- � t Contractor's Name-_.__1-. ___ -!Ie �� `�!__.._. Phone.. .. ,7171 ------ Installation will serve: Residence',' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/..... Number of bedrooms Number of baths j__-_ Lot size 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 ❑ Adobes° Hardpan ❑ Previous Application Made: Yes ❑ NoVO New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wellj._%�_O----Distance from foundation___,-,,-O_.____..Material___________________'�_"__'�,._-__�"�.___.____. No. of compartments _._.Li ---------- Liquid de th_____.r "_ Ca aci P i Size q P. ----- P ty-•-� A (� 1,c i6` 3" fline Disposal Field: Distance from nearest well._J,�.._....Distance from foundation.__�D._......tDistance to nearest lot line___.___._ Number of lines_.- ..-_-------------------Length of each line.�a'_X__J 1_.Width of trench .............. ✓` Type of filter material.s ---a-/215-----Depth of filter material------tic0".......Total length_._ ___----- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 11 Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-------------_-_Distance from foundation--------------------Lining material_.._.--_---_____-_--.---------------- 0 - _____-_--.❑ Size: Diameter.-------------------------------------Depth---------------------------------------------------.Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-___-_--_-.__--__-___-________------._.... ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- ------ -----------------------------------------------------------------------.--------------------------------------------------------------------- � -- -- -------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- 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 rules and regulations of the San Joaquin Local Health District. Si ned 1l T Di y_ • 0 - ----- - i'c---- -�.1 i-__--_- - ----- Contractor \� By:........................--------------------------------------------- F" r` -A � ''.._- (Title)-------------------------------------------- --------- (Plot plan, showing size of lot, location of system in rel to wells, buildinetc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- -------------------------------------------------------------------------- DATE REVIEWED BY------------ +----------------------------------------------------------- - DATE--------= --`----- BUILDING PERMIT ISSUED----------------------------------------------------- - - . DATE Alterations and/or recommendations:----------------------------................................................................................................................................... ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ ------------------------------------------------------------------------------------------ --------------•--•-•------•--•-•----------------------------------••---•--...--------•- ---------------------------------------------------------------# ------------- ----------------------------------------------------------------------------- ------------------------- -------------------------- FINAL INSPECTION BY--------------I, -- -------- Date_------------- ------1" ----------------------------- 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-9-2M Revised 8-'59 F.P.Co.