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APPLICATION FOR SANITATION PERMIT Permit No. (Complete' Year From Date Issued Date Issued in Duplicate) This Permit Ex fires 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. JOB ADDRESS AND LOCATION....._-._�~ ____ -�- - Owner's Name--- C. �.�./ _- - ------------------•--- -------I-----•--•----•----•-----•------------ ------- -- -----------------------------------------� Phone----------••----------------------- Address-__2 `--�� ---------- `� ------_----- Contractor's Name----- ' ----- ----� �--`-•�±, ,-------------"------ Installation will serve: Residence ,R Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _ Number of bedrooms -3 0 Number of baths/' Lot size __----.�----------, - ater Supply: Public system ❑ Community system [] Private,1K Depth to Water Table 2_5"ft. Character of soil to a depth of 3 feet: Sand"� `Gravel ❑ Sandy Loam_x Clay Loam ❑ Clay E3Adobe ElHardpan E]Previous Application Made: Yes ElNo NNew Construction: Yes No [D FHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wellZt-tn__ Distance from foundation"- _ Material-.._-_(-.1 + , ] No. of compartments---'--.-;-?---,--___-- Liquid depth_.-x_- .�..... __•. - _ Capacify- Disposal Field: Distance from nearest well,)-�_ .-Distance from foundation----1_-s?-'--_-Distance to nearest lot line...." -r Number of lines--------- ---------------------Length of each line____,3_e------------_.Width of trench-----�R_ r Type of filter material._. n ---Depth of filter material..._! "" -_._To}al 'length------ s' Seepage Pit: Distance to nearest well./_tea---`-"_Distance from foundatipn---- '.o-` Distance to nearest lot line.-- Number ofits---.-. - P Lining material_/ Ps / .:x-- ....__.Size: Diameter.__�X---��-De th__"- Cesspool: -Distance from nearest well........-_-..__Distance from foundation_-...._-....__.....Lining material-- ------------------------------- El Sfze: Diameter--------------------------------------Depth- ---------- ---:--------------- ------- ------Liquid Capacity--------------------- gals. Privy: Distance from nearest well-..._----------------------------------------- Distance from riearest building------------------------------------------------ Distance to nearest lot Pine - 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 ordinances, State laws, and rules and/regulations of the San Joaquin Local Health District. (Signed) --------- ' ��• `� ------------------------------ i -----(Owner and/or Contractor] 8r---� T.� ! ! -� ------- - �. = Ti - "�'` - - - - ------ -( 'tie)---- ------------ ----------- --------- ---- - -- -------- (Plot plan, showing size of lot, Dion of sy tem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEP-ARTMENT USE ONLY .r1 r .q i,, APPLICATION ACCEPTED BY...---- ._ r i .... DATE -: v r REVIEWED BY _----------i-- - -------- -------------------- ------- DATE----- --•------- ---------------------- - -------------------------------------------------------- BUILDING PERMIT PSSUED- -- --------------------------------- ---- •------•"------• -------- -- ------•-------------------------- DATE------ -- ---"•---------------- - �- Y _ Alterations and/or recommendations:.__--------------- Yr - +r -------------- -- s---'--- - ---------- --I-- ----- c - --------� r — - ---------------------•--�--"---.--r---------`-•-.-l------------------ �----- . - -- -- ` --�- -------- - c-� ----------------------------------------------- - FINAL INSPECTION BY--------------------- ------ Date ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street ' Stock+on, California Lodi, California Manteca, California Tracy, California FS-9-2M Revised 8-'59 F.P.eo.