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APPLFATION FOR SANITATION PERMIT Permit No. .�� (Complete in Duplicate) �`�j w Date Issued -----�G_�-_-1- 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 Po. 549. " JOB ADDRESS AND LOCAT N_ _ -- - -- ------------------------------------------- --- Owner's Name --- ----- -- ---- - --- --------------------------- ------------------------ -- --- -- --------------- -------- ----rPhorie-------- '----------------- Address------------ --------- - --- -------� ------- ------- -------- Contractor's Name---------- '� ------- Phone-------•----------------••--------- -------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J----- Number of bedrooms ---0 Number of baths ---I--- Lot size ---_ ---------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Graver Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ r Previous Application Made: Yes El. NOX ]� 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.) Se ti Tank: Distance from nt earesr well--- �---- Qista e fr m f nlation---__ _jQ ---- _ _-----__- . No. of compartm ----- _ Liquid d pth /_____--_Capacity__- 1 Disposal Field: Distance from nearest well____�_D..-.Distance from fbund/atio1____i--_-- �yDistance to nearest lot line Number of lines-------A---------------_---- -Length of each line_6_5-�--- �-.Width of trench-.-_�-7v--___-_______--__ Type of filter material- Depth of filter material----- -Total length---�Q-------- --------------------- 1 1 Se age Pit: Distance to nearest/well_____ _____Distance from fo nd It' n-- _ .._--.Distance to nearest lot line--1 7---__--- Number of pits-!----- material- ameter-___-_ �- Depth-— -- >' ------- p I 9 p Cesspool: Distance from nearest well------_-_---__--Distance from undation____________________Lining material-------------------------------------. i ❑ Size: Diameter F ------------ Dept h-. Liquid Capacity _ gals. r . _ . Privy: Distance from nearest well----------------------------------------------c--Distance from nearest building------.------------------------_-.----.-. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- t Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ ----------------------------- i --------------•-----•- ---------------------------------------------------------------•-•-----•------•------------------------------ __ 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, aAd rules arid regulations of the San Joaquin Local Health District. (Signed)-------- ------- -- ---------- -- ---- --(�Contractor) ' k Title ,�,�} ✓ �Y� ...... --------------- ---------------- ( )----410*�`_� ------------------------- (Plot plan, showing size of lot, locatio system in relation to wells, buildings, etc., can be placed on reverse side(. R' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------#----------- ------ -- ------ DATE ------- ----- - REVIEWED BY------------------------•---------=-- -- - ----------------------- DATE--- BUILDING PERMIT ISSUED-----------------------V-------------- ------------------------------------------------------------ DATE----------------------------------------------------- ------- Alterations and/or recommendations:--------------------------------------------- -----•--------------------------------------------------------------------------------------------------------- -----•-------------•-----------------------------------------------------------------------------••--------------------------------------•------••---....--•----.....-----------------------------------•--•-•-•------------ ----------•---------•--•----------------------------------------- --- ------------- --- -------------------------------------------------------------------- ----------------------------------------------- FINAL INSPECTION BY------------- ---- --- --- ------- 1 --! Date------------- �C ------------•---- SAN.JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-�-2M , Revised 1-57 F.P.CO.