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APPLICATION FOR SANITATION PERMIT Permit No. ... ........ 3 (Complete in Duplicate) f I This Permit Expires 1 Year From Date Issued �.."f ate 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION_1/0--�_�-_--------- Owner's Name----� / ----------------------------------------------------- --------------------------------------------- Phone.................................... Address--------------------- ---------------------------------------------------------------------------------------------------------------------------------------•------------------------------------ Contractor's Name--- `�1 L� -- ---•--------•-----•-------•-----•--------------•---•---- Phone................................... Installation will serve: Residence ❑ Apartment House ❑ Commercial a' Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___1___ Number of bedrooms ._Z_. Number of baths Lot size _.,' _ c1± ........................................ Water Supply: Public system ff-,*-Community system ❑ Private ❑ Depth to Water Table / ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0--Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes EA--No ❑ FHA/VA: Yes ❑ No 94--'. 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-----------------Distance from foundation....................Distance to nearest lot line----------------- 0 Number of lines-----------------------------------Length of each line------------------------------Width of french------------------------------------ Type -_----.--_- •---_.-------__--___ Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ / Seepage Pit: Distance to nearest well__-9-l-----_--Distance from foundation---�4__-.___.Distance to nearest lot line-_ :____. Number of pits---------- Lining material__ ICAC _-.Size: Diameter---,�------------Depth-_-- _.-___----_____- •� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_.----_________-_-_--_.__--__-___._ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Q I'. Privy: Distance from nearest well------------------------------------------------- from nearest building-__-_-____--__-___-________-__-_____-_. ❑ Distance to 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 regul tions of the San Joaquin Local Health District. (Signed)------------------------------------------------------- --- ---------- (Owner and/or Contractor) --- ----------- ------ - ----- --- --- ------------------ By:........................................ --- -- ------------ ------- ---------------------------------------------------- ---(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 - -- ----------- ------ DATE------- ...... f f� - REVPEWED BY ------------------------------------------------- ------ >'i - - ---------.-•---------------------------- DATE-------� /------------------------------------ BUILDING PERMIT ISSUED---------------------------- ------- DATE Alterations and/or recommendations-------------------------------------- -------- --------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------•----------------------------- ------_----------------.............--•-----------•------------------------•------ ...................--------- ---------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------•--------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------••....... ------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.--------- % ----------------------------- 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, California Tracy, California ES-9-2M Revised 8-'59 F.P.Co.