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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) bate Issued .__ `=-�D �e This Permit Expires 1 Year From Date Issued i404=z Application is hereby made to the San Joaquin Local Health District for a permit to construct and instThis application is made in compliance with County Ordinance No. 549. J � � OB ADDRESS AND LOCATION ----------------- -------------- Phone------------------------------------ Owner's Name-----eaIVIt .----- --------•--------••- Contractor's Name --------------------------------------------------------------------------•-------------------------- ------ Phone.---------------------------------- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trai}er Court ❑ Motel ❑ �O1thQer C]Number of living units: _�____ Number of bedrooms �___ Number of baths t- k-- Lot size ----11.0_�.a,-__T-.-l__________________________ Water Supply: Public system [–] Community system F] Private� Depth to Water Table �.— ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam M Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No J� New Construction: Yes [� No ❑ PHA/VA: Yes ❑ No ❑ ^ TYPE OF INSTALLATION AND SPECIFICATIONS: 1nl (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__C__.._____Distan e from foundation__�_d_ _______-Material__________ _____________ _______..______----. { _____ __- Size_---- -' -__b_.---Liquid depth____.q__-_----___----Capacityl/,_�_____-- No. of compartments____- - Disposal Fie4d: Distance from nearest well__7n'-----D.istance from foundation�q. _ __._____ _-Distance to nearest lot line_ e'f----- r. + f NA Number of lines--;-,ria-2--0r----------------- Length of each line_---�0----------------.-.Width of french_.f _ -_---------------------- Type of filter maDepth of filter material,___ __ _________Total length--- _ Q_._=------------------------ _ Seepage Pit; Distance to nearest well---------------------'Distance from foundation ------------------Distance to nearest lot line__.__._________. ti ❑ Number of pits----------------------Lining material--------- -------Size: Diameter-----------------------Depth-----------------.--------------- Cesspool: Distance from nearest welf�________________Distance from foundation_____._..._._.____.Lining material-__.-_.----------___---_--_________. [] Size: Diameter--------------------------------------Depth'---------- ---------------------------------------.-Liquid Capacity--------- ------------------gals. Privy: Distance from nearest well _.._____________-------------------------------.-Distance from nearest building________.______-__---_----------.---.-. ❑ Distance to nearest lot line---- -------------------------------------------------------------------------------------------------- --------- t t Remodeling and/or repairing (describe) •, --- -------------------------------------------------------------------- / • ti -•� •_____________________________.----________________._._____-------- ----------------------•--'------- -----------'------------ --•----- -----___-----------------------'--'---------s---"---------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations-of the San Joaquin Local,Health District. i -(Si ned . -- ------------- ------------------(Owner and/or Contractor) BY• -------------------------------------------- i-------------------------- ----------4------ -------------------(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 APPLICATION ACCEPTED BY_ .x - == ___ DATE---tY-----------`-----0 REVIEWEDBY---- -=--------------------------------------------------------------- ----------------------------------------------- ------ DATE---------------------------------------.-___------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- ----------- DATE Alterationsand/or recommendations------------------ ---------------------------------------------------•_-------------------------•-------------------•------•-------------------------------- ------------------------- ---------- ------------------------------------------------- ------------- ----------------------------------- ------------------------------------------ ------------------- FINAL INSPECTION BY• -------------------- Date...G $ �'° ---- --- ---------------------------- 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.