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11`� APPLICATION FOR SANITATION PERMIT Permit No. .................... (Complete in Duplicate) Date issued __ a This Permit Expires 1 Year From Date Issued �S f ^� Y3Z3 � 4 . 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 )ounty Ordinance No. 5494e. JOB ADDRESS AN LOCATION_ ------- --- ------------�i ----------------------------- Owner's Name----- � �- - --- --------••-•------- -------------------- -----------. Address--- -- Contractor's Name--------- --------------------------- '_ .. - ----------`-4--=- `�rr_� PhoneKd.. � Installation will serve: Residence ❑ Apartment House ❑ ' Commercial ❑ Trailer Court ❑ Motel ❑ Other ' -------------------------------------- Number of living units: ___.__. Number of bedrooms ________ Number of baths��-- Lot size _ __ Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table 2Q ft_ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan [j Previous Application Made: Yes ❑ No [ New Construction: Yes ❑ No 2---_F_HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _. 3ti k: Distance from nearest well----------'___-__Distance from foundation--------------------Material_______---___________-__--________--____---.__- No. of compartments----------- --Size------------------------------ Liquid depth Capacity---------- ---- lk/J Disposal R d: Distance from nearest well-P-4?---:----Distance from foundation___-_-------.Distance to nearest lot line____________ Number of lines.--•------�------__--- � Length of each line----_j.0------------------------Width of trench_.-._-25�_�;----------------- Type of filter material____. ;t�r -Depth of filter material-__-- _---------Total length----------_30-__________________._ f Seepage Pit: Distance to nearest well_fG _�----__-_Die#once fpm foundation_______-___Distance to nearest lot line___°._________ [y� of pits------J-------------Lining material----_,0-�A�-----Size: Diameter------ -r -._------Depth_-- ---------------------- Number Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-___---_-_____----_____-_____-___---. ❑ Size: Diameter----------------- --------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. -------------Distance from nearest building----------------------------------------- Privy: Distance from nearest well_______________________________ ❑ Distance to nearest lot line--------- ------------------------------------------------------------------------------------------------------------------------------- -. V Remodeling and/or repairing (describe)----- -- ------------------------------------------------------------------------------------ ------------------------------------------------------• ----------------------------------------------- --•------------------------------- - ----------------------••----------------------------------------------------------------------------------------------- - ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance, a laws, and rules and regulations of the San Joaquin Local Health District. Si ned 1 Contractor) (Signed) 9 )-------- -- 1 1 1 .............. -------- - - {Owner and/or C or) i_Lr__14�c _ Title y Y:------------------ - t (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--- ------- - -_1;----- ------------------------------------------------------- DA7E_ '3 --- ------•---------------- ---------- REVIEWEDBY------------------------- - DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------ ---- DATE------------------------------------------------------------ Alterations and/or recommendations:------------------------- ----------------------------------------------------------------------------------------------------------------------- -- -------------------------------- ---------------------------------•----- --------•----------------------------------•--------------•- ----------------------------------------------------------------- ------------------------------------ ------------------- ------------------------------ ------------------- --------------------------•---------------------- ---------•----- r FINAL INSPECTION BY:_-i-,,;;: ----- Date_ `` �44----------------- -------------------------------------- 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 r� ES-9-2M Revised 8-'59 F.P.Co. 5