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APPLICATION FOR SANITATION PERMIT 4 ~ " {Gorr plet8 in Duplicate} ' This Permit Expires i Year From Date Issued Date Issued 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___________________ SJo� 3 � 1-R ------------- Owner's Name --------- --- ~ (/ =------------- Phone __------- Address---------------IL,, - ------------ -------------------------- Contractor's Name------ ------ �e�r--w-¢-f-�t�^- c� G�.-s Phone ----------------------------------- Installation will serve: Residence gj Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __�_- Number of bedrooms __��.__-- Number of baths --- Z_ Lot size _--_---3_-----_f`S__C� • _ •--- 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 ❑ Adobe Hardpan ❑ Previous Application Made: Yes [] No Eff New Construction: Yes �a_ No Q' FHA/VA: Yes ❑ Nox TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic nk: Distance from nearest well_______________ Distance from foundation -------------------- Material ._._ " d No. of compartments- Size -------Liquid 4depth ------------------------ --Capacity-----------••---------- ispos I Field: Distance from nearest wefi.__----_____._._ Distance from foundation ____-..________.__.Distance to nearest lot line_______________ Number of lines ----------------------------------- Length of each line -------------------------- -------- --.Width of trench -- ---------------- ---------- Type of filter material --------------------- .---Depth of filter material ----------------------- Total length ____--__________: ----------------------•- Seepage Pit: Distance to nearest well ----- crc-Cz-------- Distance from foundation____/Gf ---- Dista c to nearest lot lin. ;L CK Number of pits..._ --- ------ ______-Lining matenal_#_�_o-1T-_---.Size: Diameter_.--_------_- Depth_.__F?----_,{. Cesspool: Distance from nearest well_Distance from foundation__________________.Lining material__._______-__---_____ ❑ Size: Diameter----------- ------------------ -----Depth-- ------------------------------------ - ---Liquid Capacity-- --------•------- -------gals. Privy: Distance from nearest well__________________ ---------- ..-Distance from nearest building -------- --- ❑ Distance to nearest lot lin I;— -------------------------------------------------------------- -------------------------------- --------------------- -------------- Remodeling andf. pairing(describe):-f�----------------- �----= --- '--,--------- •----------- -•--------------------------•-----------------•----------------------------------------------------------------------- ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsand rules and regulations of the San Joaquin Local Health Diftrict- (Signed)-----------4�� (( -- ------t�J�ft�----_(��-✓�--- - �'-------��-'-------- (Owner and/or Contractor] By:----------- ------------------------- - Tale ------ (Plot plan, showing size of lot, Iocation of system in relation to wells, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY ------------ APPLICATION ACCEPTED BY--- ----------- .2--- ---- ----------------------------------------------_--- DATE-------• �----------- REVIEWED�' BY --------------------------------------------------- DATE ------------------- I DIN PERMIT ISSUED---------------------------------------------------------- DATE --------------------- ----------- -------------------------- A aerations and/or recommendations:______.___._- ::_ _- _____------__.__ "` - — ° ----------------------- -------- ---------------------------------------------••---------------------------------- ------------- '---------------------- -- ---------•-------------•--------------------------------------------- r----- -------------------------------------------=!-------- -------------- -------------------------------------------- ------------------- ------------------ 7 --------------------------------------------- ----------------------------------- -------------- -- `FINAL INSPECTION,BY:------------- Date'-"--C�- SAN JOAQOIN 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 Revlsed 6-'59 f.P.eo. :f ,1 , f