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APPLICATION FOR SANITATION PERMIT Permit No. _ _Q. _____ F (Complete in Duplicate) Date Issued _/_ i_.S-----__ 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 Vith Coun Ordinance No. 549. (�f/(_xf� . is � J JOB ADDRESS AND LOCATION -------------- -- --------- -4--�"-------- -------- Owner's Name -; r /"' --�------ Phone------- ------f --- G r �-- Address -------- - --------- ---- - �' a' �j ----- -------- ----- Contractor's Name------------- -------------------------------------------------------------------------- -----------•- ---- Phone-------------------- Insfalia+ion will serve: Residence ❑ Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms -------- Number of baths ________ Lot size __ --_______________i`_____-_-__ Water Supply: Public system ❑' Community system'❑ Private�� Depth to Water Table 60_ ft. j Character of soil to a depth of 3 feet: Sand ❑ Gravel Ill, Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No V New Construction: Yes I)K No ❑ ' FHA/VA-. Yes ❑ 'No TYPE OF INSTALLATION AND SPECIFICATIONS: l'• �-. (No septic tank ar cesspool permitted if public sewer is avilable within 200 feet.) Septic Tank- Distance from nearest weli_ )-/_rDi�tn ce from found ion___J__5___-____Ma er)al___� No, of compartments________?/________Siizzze_ / _ __ Liquid dept,____�____�_____Capacity___��_Q_� Dis osal Field: Distance from nearest well_ i.f�istanG�ofn foundation__I_�`___-Distance to nearest lot line__ P� Length f , fWidth o french-._ [Number of lines- I Type of filter material___ _J_ setoff Itermaterial____-____ ----Total len9th_________- 'P_ 0 1 Seepa a Pit: Distance tonearest well IOVI i nice fro foun etion____2'_G_-____.Distance o nearest lot line__ _ ------ Number of pits__ ___________Lining material_ lize: . � . Depth________ --------- Cesspool: Distance from nearest wel!_________________Distonce from foundation--------------------Lining material __.__-__.___:__ e _-�_________ [] Sze: Diameter--------------------- -= ------_.-Depth----- - ----- ----- -------------- - -Liqurd Capa�itY•-------- :--------.'------9_ .al_s_, Privy: t Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------- ❑ Distance to nearest loft line----------------------------------------------------------------------- --------------------------------------------------------i""------------- Remodelingand/or repairing (describe)--------- --------------------------------------------------------------------------•-------•--•--- ---•-------•---•----------------•-------------------•- I ► - -----------•---•------------ ---------•---•----- it --------------------------------------------------------------------------.---•---- ..--------------••-•---------------------------------------------------- ----------------------------------- � i I hereby certify Oat] have prepared this application and that the work will be done in accordance with San Joaquin,"County F ordinances, State laws, and rules and jreOaans of the San Joaquin Local Health District. (Signed K --------------------------------------------------------- (Owner and/or Contractor) - -------------------------------------------------------------------------- --Title-------------------------------------------------- (Piot plan, showingsize f lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- - ------ DATE !' ------------------ - --------- REVIEWEDBY--------------------------------- :------------------- =------ ----------------- DATE------------- �..-._.. `�` BUILDING PERMIT ISSUED DATE ---�-- /� Alterations and/or recommendations:-------.----------------_ ___ --------------------------`r ""' i, --------------------------••-------------------------------- --------------- ------------------------------------------------------------------ --•-----------------------------------------------------------: ------------------------------------------------ ------------------------------------------------------•-------------------------------------------------------------•--- ----•---•--••----------------------•- --- m -------------------•--------------------------- ----------- - ----- ---------- FINALINSPECTION-'BY----------------- --------------- -------------------------- Date----------- / ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT m 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street li Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-2M Revised 1-57 F.P CO. j r f