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APPLICATION FOR SANITATION PERMIT Permit No...1.3-e.�Z/_ (Complete in Duplicate) This Permit Expires ] Year From Date Issued Date Issued ..__l._) / �n Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the worhherein described. This application is made in compliance with County Ordinance No. 549. 01'7—. ,W0 -O -2 OB ADDRESS A D LOCATION--- Owner's Name -f �`L - --.-- Phone _---•- "II /��i }i2� Contractor's Name___- ----------------- Phone----------------•------._...__ Installation will serve: Residence ❑ Apartment House [❑ Commercial ❑ Trailer Court ❑ Motel )a Other Number of living units: -------- Number of bedrooms ________ Number of baths _______ Lot size _____________________ _ i 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 ❑ i Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: O (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well______________ Distance from CIP --D;stance ❑ No. of compartments - -------------------- ---Size ----------------------------•--- Liquid depth -------------- ----------Capacity.. I � o' _ ^* Z Disposal Field: Distance from nearest well.'>��.'�Distance from foundation __.___._-------- Distance to nearest lot line_____________ , ,] Number of lines__.._____ y .____ ength of each linef1r®_________________Width of trench_,1--__y----------------- Type of filter materi �_13epth of filter materiaL._�� I Total lengfih__�--- Seepage Pit: Distance to nearest wet ----------------------- Distance from foundation ------ .------------- Distance to nearest lot line ----------------- 171 Number of pits.------------------- Lining material ----------------------.Size: Diameter.------------------- Depth --------------------------------- i II Cesspool: Distance from nearest well ----------------- Distance from foundation___._._._____ .__._Lining material-_________________________________._. r \^ ❑ Size: Diameter ---=---------------------------------- Depth.--------------------------------------------------- Liquid Capacity ---------------------------- gals, - Privy: Distance from nearest well________________________ _Distance from nearest building ---------------- o nearest lot line------------------' I ---------------- ---- -- Remodelingrepairing I and/or re airin describe ' ]:__L - ---------- ------------- --- -------------------------------------------------- ---------------------------------------- ' = ------ - - ------ ------ ----- ----- - ----- - - -- - - - ------------- - - --- -- --- ------ - --- --- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, and rules and regulations of the San Joaquin Local Health District. 4 {Signed) �� -------- ''�---------------------------------------------------------(Owner and/or Contractor) B--------------------------------- ----- - Title � _ - I (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_r,e/,,45—,,'DATE -------------- REVIEWEDBY DATE -!n ------ - ------------------- -------------------------------------------------- --- -----------•-------•------------------- BUILDING PERMIT ISSUED------------------------------------�---- - - _ --------------------- DATE.""'.'-{------ -------------------------------------------- - --------------------------------- Alterations and/or recommends#ions::----_____.._.------------------ --------------------- --------------------- _------------------------------------------ i _____________________________________________________ _ _ _ w FINAL INSPECTION BY _ Date -----.-/- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi. California Manteca, California Tracy, California ES -9-2M Revised 8-'59 FLP CO3