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APPLICATION FOR SANITATION PERMIT Permit No. .-� �-�.Ij i' (Complete in Duplicate) I' This Permit Expires 1 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. JOS ADDRESS AND LO --- .--•------------- - . __ --- Owner's Name_____ 77�---------- --------- ------------------ ------------------------- Phone-----•------------------••-•----•-- Addrress----- ------ p ------- - 2--------------------------------------- -- ----------- ntractor's Name---------- ------ Phon - - /,14r7 Co - Installation wiil serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1.14 Number of living units: __ ___ Number of bedrooms _- .- Number of baths I---- Lot size ___�---X_�0�--------• Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 00ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑.. Clay Loam ❑ Clay ❑ Adob Hardpan ❑ Previous Application Made: Yes ❑ No". New Construction: Yes ❑ Noa_ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (N epfic tank or cesspool permitted if public sewer is available within 200 feet.) 4e�ptic T Distance from nearest well------------- Distance from foundation--------------------Material-------------------------------------:._______-. � No. of compartments-------------- ---- ---Size--------------------------------Liquid depth--------------------------Capacity----------------------- Distance --------- --- d: Distance from nearest well. jfDistance from foundation.- ____._____Distance to nearest lot line _______.Width of trench__ __________ _______ e 9� Number of lines___._____-]_____________�___�_/_____ Length of each line �Y-�� Type of filter material____ VCVKC __De th of filter material_---/ Total len th__,;6V-------------------- S _______________________ Seep a Pit: Distance to nearest well___A(CAI- -"Distance m fouundat'son---/0--- -----.Distance to nearest lot line- ------ h Number of pits----:1--------------Lining material__, _ �_.Size: Diameter-- lr-------Dept`rt--- -'p --------.-----• r Cesspool: Distance from nearest well________________Distance from fou"ndation._.._._..___-_.___..Lining material-______.___________.__.___________-_. r iI ❑ Size: Diameter--------------------------------- ----Depth'----.---------------------------------------------Liquid Capacity----------------- --------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__________._____----__________.__________- ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------- -------------------------------- I, Remodeling and/or repairing (describe):_ ._ _ _ ------ - -------- ----- X'- �-----• ---------- ------------�--- = ------------------------------ ---------•------------- --------------------------------------• --------- ------------------------•--------------------------------------------•-------------------------------- V I hereby certify that I have prepare is a plication and that the work will be done in accordance with San Joaquin County ordinances, State la , and les and egula ' s of the San Joaquin Local Health District. it (Signed) ----r'-- ------ -- ---- I---------------------- -- - ------------- -- -=------------ -COwner and/or^ ontractor) By:------------------- ,.. a� (Title)----- (Plot plan, showing size of lot, location of syste in rel tion to wells, buildings, c., can be place an reverse side). ii FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------•---- ---------------------------------------- DATE----------5—__!Y—_A-0- - - ------•----------------- - REVIEWEDBY--------------------------------- ----- ----------------------------------------------------------- --- . DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE--------------------------- --------------------------------- Alterationsand/or recommendations-------------------------------------- -------------------------------------------------------------- ------••----------------------------------------------- ----------------------------------------------------------- r i ------------ ------- --- ---------------- ------------------ ----------------------------------------------------------- ,-' ---------------------------------------- ------- ---------------------------- ---------- l! Date----- `7 r �� - ------------------------------------ I-FINAL INSPECTION BY:.__e_(� _-._. --- 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 1 ! I� 4 d ES-9-2M Revised 8-'59 F.P.CD.