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APPLICATION FOR SANITATION PERMIT Permit No. ....Il_.?...7.. _-__ (Complete in Duplicate) Date Issued —This Permit Expires l Year From Date Issued n Application is-hereby made the Sen Joaquin Local Health District for a permit to construct and install the wor herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A LOC ION----� d- -f-_s{ _ +�� ' � =-'---- '' �, / Owner's Name---- - --�--------•--•----------•---------------- -------- Phone------------------ -------- - ---------- ;se __ _ _. -.'�.. _-_-__- ___sVf-WY-----___ � __ _____ p_-•-_.-..____.____________________________________________________________ Address_______________ I I Contractor's Name--- -------- Phone i Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J___ Number of bedrooms9_ Number of baths o"2-- Lot size ----4 Supply: Public`system E] - Community_syster,El Private �epth to Water Table AI f}. , Character of soil to a depth of,3 feet: Sand ❑ Gravel L] Sandy Loam Clay Loam El Clay [:1 Adobe E] Hardpan ❑ Previous Application Made: Yes ❑ No e New Construction: Yes �lo ❑ FHA/VA: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) O Septic Ta k: Distance from nearest wel4__ ______Distanc /from foundation-__��___--__.Matenah,__ _�/r __ _ _ _.___-____- q 1A ------Capacity..._t2_ y No, ofcompartments-__-- __ - M --(�---- -- depth-------`-_-" i tante from neares}-wel _ _Dk stance from fodatioln.ul/ Disposal F' Id: D's �_�.Distance to nearest lot line__��____-- Number of lines----------- -_--'__________Lengfh'of each line_____�ee-_6``--___.Width of trench-____�- ,` �-____--__-___ ! -----------•--• - Type of filter mater3al_��epth of filter-material----,��______Total length--------�� _ s --�2 ` --- Depth-----o� 1. Seepag t: Distance }o nearest well_%j9QV-_/'_Distance fr foundation-� e_Q___-.D•st n e to nearest lot line— _1 [ Number of pits_____-_--_----__Lining material_:_ QSize: Diameter._. i Cesspool: Distance from nearest well------- Distance from foundation---------_____-.Lining material_________________________ ❑ Size: Diameter-------------------------------------De th--------------------- ------ ---------------------Liquid Capacity gals. Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building----------------- --.-_______--- ._----. O ❑ Distance to nearest lot line------------------------------------------------------------------ r` --------- Remodeling and/or repairing (describe):----------- -------�---•---------------------•---- ••-- ----- a ---------------•------------- ---------------- 15-AN�--'� -------4AP6---------_-6-1�----- ----�!- == ----------- --- --- ------ --------------------------------------------------------------------•---------------------------------------------------------------------------------------------------- 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) - � --- ------------- ----------------- ---------------(4wrre;3CS%Lor Contractor) (Plot plan, showing size of lot, location of s m in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY-------•---- --`------------------------------------------------------------- DATE------ fry" ' ------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------•---------------•--- ------------------- DATE--------------------------- --------------------------------- Alterationsand/or recommendations:-------------- ------------------ ------------ -----------------------• ----------•-------- ----•--------------------------•---•------------------------------- --------------------------------------•----------------••----------------------------------- -------------------------------------------------------------------•----------------- --------------------•---------------- j ---- ------------- ---------------------------------------------------------------------------- -- -------------------------------•--------------------------•-------------- ----------------- FINAL INSPECTION BY: ------rte ---- -------------------- Date_&--- � �� ---------- -- --------------------------------- 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, Californias Tracy, California s 4 FS-9--2M Revised 8-'59 F.P,Cc.