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�v APPLICATION FOR SANITATION PERMIT j Permit No. (Complete in Duplicate) Date Issued ___�1. .- This Permit Expires 1 Year From 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. } `1 .JOB ADDRESS AND LOCATI N . ._Sz__�S ' - -Xf, Owner's Name------------------------ -----•-- --�----- ------------------------- ------------------------------- Phon - ------------- Address * -- UPhone........Contractor's Name-----------------------------------•-•------------------- - --- Installation will serve: Residence �9_ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. ____ __ Number of bedrooms _ -- Number of baths __[-___ Lot size ---------------&0- -_--- ? 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 R Hardpan ❑ Previous Application Made: Yes ❑ No`& New Construction: Yes ❑ No bR� FHA/VA: Yes ❑ NoOK TYPE OF INSTALLATION AND SPECIFICATIONS: � (Nng eptic tank or cesspool permitted if public sewer is available within 200 feet.) �e tit , , Distance from nearest well_________________Distance from foundation-------------------.Maferial------.-_____________________________._...-._-. I '$ No. of compartments------- ------------------Size--------------------------------Liquid depth------------- -- ---------Capacity------------------ Disposal Field: Distance from nearest well----" --------Distance from foundation___.�_/^v'_-------.Distance to nearest lot line_____-. 4L �- Number of lines---------------j-----------------Length of each line-------___�..7--_ -------Width of trench________ -54_-V_____------- Type of filter material __- - �._-Depth of filter material-------l(�______Total length______________________�0-.-____ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------.......Distance to nearest lot line__.____.___-__.._ ❑ Number of pits----------------------Lining material-------------------.__-Size: Diameter----.------------------Depth-_--------------------..--------. (� 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 line---------------------------------------------- --------------------------------------------------------------------------------- -------------- Remodeling �n /or airing describe):-------- ------------ 4 - �. = 3 46--110M,------------ ----------- ---------a------- -------------7 - --------------------------------- - -------- ---------- ----------------------------------- - - --- ---•----------------------------------------- ----------------------------------------------------------------------------------------------------------------- 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, an rules nd regu ions of.the n Joaquin Local Health District. (Signed) - ------------ ------------------- ---------------- -----------------------(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 APPLICATION ACCEPTED BY-------------------- - -- ---- ----------•------------------------------------- DATE------------- - REVIEWED BY �--��7--- -- ---------- --------- - --- ------------------------ -------------------------------- DATE----- --------- BUILDINGPERMIT ISSUED--------------------------------- -------------------------—-------------------- ----------------- DATE------------------------------------------------------------- Alterationsand/or recommendations-------- -- ----------------------------•------- -------------------------------------------------•--------------------------------•---------------------------- --------------------------------- ----------------------------------- ----------------------- -----------------------------------------•------------------------------------------------------------------------------------- --------------•--------------------------------------•---•------------------------------------ ------- --------------.-------------------------------•------------------ ---•------------------------------------------------ ------------------------------- --------------------------------------------- -------------- ------------ -----------------------------------------------•----- ------------------------------------------------- ----------------------- - a FINALINSPECTION BY------------------- -- ----------------------------- Date- - - ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Streef 30D West Oak Street 132 Sycamore Sfreet 814 North "C" Street Sfockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F,P,Co.