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11kip ?- �17 APPLICATION FOR SANITATION PERMIT Permit No. ___ ... �• II<� (Complete in Duplicate)7 A Date Issued ___ z, -� j \ 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'di scribed. This application is made in compliance with County O/--' e No. 549. ��'/ -----------•--- --------- ---------------•------- JOB ADDRESS AND LO ATI ` -- -�'`�------------- Owner's Name --- Phone------------------------------------ -= -- 1� ------��-- ..__ _....-----... �------------- Address------------- - ---- ----- --------------------� Phone or's Name_..----- -----� ------------------------------ Contract { Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ------------------ Number of living units: I---- Number of bedrooms _.__ _ Number of baths .J-_-_ Lot size _________,l am-1c� -- Water Supply: Public system ❑ Community system ❑ PrivatXVL, Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand [j Gravel ❑ Sar am ElClay Loam ❑ Clay ElAclobex Hardpan C] Previous Application Made: Yes ❑ No ❑ New Construction- Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) pti 1 Distance from nearest well-----------------Distance from foundation--------------------Material------_--...___--..--._-__-----___--------..__-. ( � No. of compartments--------------------------Size-------•-------• Liquid depth----------- --------------Capacity---------------------- DispE IT ield: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- NuDepth -----------------------Tmber of lines---------------- ------------------Length of each line------------------------•-----Width of french---------------------------------- ( Type of filter material-------------------------Dth of filter material length------------------------------------------ i el W Seepage Pit: Distance to nearest we4l---,CaQ----------Distance from foundation----/Q--------DistaVp to nearest lot line_._ --. ._ .____ X-S Number of pits---.----t------------Lining material--.--21:)!-----Size: Diameter- - ------------Dept h---.. ---r--------------- cesspool: Distance from nearest well---------------_Distance from foundation.-------------------Lining material--------_-------------..___----__--- ❑ Size: Diameter-------------------------------------Depth--------------------- ---------- -----------------Liquid Capacity------------- --------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----._.-_..___----.-_-_____-----.----.- ❑ Distance to nearest ]of line------------------------------ ------- - ---------------------------------- 4::.;11 ----- ------------------------- Remodeling and/or repairing (describe):__. -_-_ - - -------------- _ _ _ _ ___ _____ ___ __ _ ___ --- -------- ----- ---- - - - -------------- ------------------------------------------------------------- -- s --------------------------V----------•-------- ------------------------ --------------------------------------------------------------------------------------------------- I hereby certify that I have prep t is a plication and that the work will be done in accordance with San Joaquin County ordinances, State law d r s a regulat' s of the San Joaquin Local Health District. (Signed)----------- - -- ----P- --------- -------- ..- _ ___.. c _ __.___- [Owner and/or Contractor} -• ..__ - __. _ By:_------------------------------------------------------- - -------- (Title} - ------------- - (Plot plan, showing size of lot, location of system in relation to wells, build gs, etc., can be pl ced on reverse side). FORDEPARTMENT USE ONLY DATEF d------------------- -- APPLICATION ACCI=PTED BY- ---------------------------- - ------------------------------------ -- ------------- - REVIEWEDBY--------------------------------------------------- ---- ----------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------ ------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations-------- -- ------------------------------- -------------- ------------------------------------------------------------------------------------------------- _,� ------------------------------------ ----- - - - ------------- ------------ ----- - ---- ------------ - --- - --- - - --- - - -- f ---- Date FINAL INSPECTION BY- -- .---.-�- // ------- f � d ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1:10 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.Co.