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i 1 Permit No. .�..---APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) �/c Date Issued --- __ _ ________-- 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. JOBADDRESSZD LOLTC - ---------- -----• ----------- --------------------------------•---------------------------------------•------------------ 1 Owner's Name _ �u } •-------------- -------------------------------- -----.-- Phone_► ' ---- ------------•------------------------------------------- ------•------------------ Address y`�7IS ' �� // [� Contractor's Name-- c '_ Phone.. = Installation will serve: Residence{Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel-,[3 Other ❑ Number of living units: 1.--__ Number of bedrooms --2., Number of baths -1----- Lot size -----------------•-------_ Water Supply: Public system .EE--Community system ❑ Private ❑ Depth to Water Table -6-0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe gr-Hardpan ❑ Previous Application Made: Yes ❑ Noew Construction: Yes ❑ No I<FHA/VA: Yes•❑ No TYPE OF INSTALLATION AND SPECIFICATIONS:' 4 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-------__.______Distance l- _ from foundation___________________Materia __-_---______________.____-.--___..__ -__-___-- No. of compartments------------ -------------Size----------------------------•---Liquid depth--------------------------Capacity-•--------------------- k Disposal F� Distance from nearest well_________________Distance from foundation-______--____.__.---Disfance 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--,---------Distanc-efrom foundation_1Q-----------Distance to nearest lot line----------------- su --Lining ma#erial___ Q(`ff-----.Size: Diameter--.3.3---.-.-----Depth---.----Z �--------- Number of pits-------1---------- -- Cesspool: Distance from Inearest 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 linen---------------------------- -------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):- 1 f -----------------------------•-------------------------------- -------------- ---------------------------------------------- ------------------------ --------------------------------I---------------------------------------------------------------------------------•------------------------------ ;----------------------------- 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 an rules and regulations of the San Joaquin Local Health District. (Signed) --------------------------------------- -------------------------- -----(Owner and/or Contractor) By:------------------------------------------I---------- -- --------------------- -----------------------------------------------(Title)---------- ------------------ --------- ------------- -- -- --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed�onreverse side). �r I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ .-;-0-.--____ — Z1,�--- DATE- - - -C------------------------------- REVIEWEDBY--------------------------- ---------------------------------- ----------- DATE-------- --------------•------------------------------------ BUILDING PERMIT ISSUED------- _ --------------- =-------------------------- DATE------------------------------ ------------------------------ ------------- Alterations and/or . R�. - Alterations and/or recommends inns: �___. ------------ -----• = -- �---�- 1, - ------.-.- �- g---c - _ 4 ---------------- ----- 1 f ------------------------------------1-1--------------------------------------------- --------------- ------------- FINAL INSPECTION BY:-<-:= i - Date-------- �tr� 4• d--------------------------------------- r t SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California a ES-9--2M Revised 6-'59 r.P.eo.