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APPLICATION FOR SANITATION PERMIT Permit 1`47% .l_. .3_ � �4 (Complete in Duplicate) 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 Counnttjy Ordinance No. 549. JOB ADDRESS AND LOCATION---/��DC--- !{ Owner's Nam -----j1,.--------------------------------------------------- --------------- Phone-----•------------------------------ Address-----------•- a Contractor's Name----C r 7 ------- -------.--. Phone----------------------------------- Installation .------•----------------• -- --Installation will serve: Residence [ k-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. --/_--- Number of bedrooms .- Number of baths ---/--- Lot size _. __ _Zei.-------------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table _-'Irft. " Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe gal', Hardpan ❑ Previous Application Made: Yes ❑ No ail' New Construction: Yes EIO<o ❑ FHA/VA: Yes ❑ No Ems" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material _--_-.----.----_-..-_------------_--.--------_-. ❑ No. of compartments--------------------- ----Size--------------------------------Liquid depth------------------------.-Capacity----------------------- Disposal Field: Distance from nearest well--ilio-ht---Distance from foundation.-. ` --_._.-___..Qistance to nearest lot line_. ..._____ Tu eber of of filternes mat - Length of each line--------3.o- ------------Width of trench------- Z ------------------ Yp erial--"�u.r_k----_----Depth of filter material---.1 ----------Total length--------- _00- ---------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- \ ❑ Number of pits-_------------------Lining material-----------------------Size: Diameter-----------------------Depth--..--------------------------- -- Cesspool: Distance from nearest weJ1------------ -----Distance from foundation---------------.-_..Lining material--------------.------_.----.---_-----. - �y Size: Diameter--------------------------------------De th__-------------------- ---- ---------------------Liuid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----_----_.-----------.--__-.--._---.---.. ❑ _..,.o..Dims+6h6e o nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- 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. Si ned / ( g }------------ -- 1�------------------------------------------------- - -------------------------------------------------------- --------(Owner and/or Contractor) By:--------------------------------------•---•-------------------- -f (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 '^r'`----1------- ------------------------------- DATE---- - 6-el REVIEWEDBY--------------------------------------------------------------------------------- ------------------------------------------ DATE----------------- •--------- ----------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------•------ Alterations and/or recommendations:------ --------------------------------------------------------------------------------------------- ------------------------ t --- --- `?` ----- ----------------------------------------------------------------- -------------------------•-- ---------------------------------------------------------------•----------•---------- ------ -------- FINAL INSPECTION BY:...._ -� tl -� Date.------.. -- ---- - - -- -------------- M SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stroat 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F,P,Co.