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r� . . ._ .3.5 APPLICATION FOR SANITATION PERMIT Permit No. .lr�_ ______ (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued __ _-1__.y-___6v 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 LOCA ,ION_.-______G�-s - :--47 Owner's Name----- --- l -- --------- ------------------ -- -- Phone-----•---•------------ - -•-------- -•---••----------------- - ---- ----------- - Address t = - Gontractor's Name---------• --- -_-'-- -- - _ ----------------------- Phone------••---•------------ Installation will serve: Residence ®1"Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ Number of living units: ---f__ Number of bedrooms ---L Number of baths __/_._ Lot size X f ----------------------_ Water Supply: Public system {17�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 Hardpan ❑ Previous Appli&afion Made: Yes ❑ No L4--'—New Construction; Yes RR"Ro ❑ FHA/VA: Yes ❑ No Q� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearestwell___' __ - Distance/from foundation__._-Q_.__._.Material_�- - No. of compartments_.-_/ --+____-----__Size_xX--- Liquid depth__._ -_{-� _-._Capacity._ _?P-,n------ Disp,,o_sal eid: Distance from nearest well ------Distance from foundation-----f9- ___.Distance to nearest lot Iine_"1---�--- Number of lines-------Y----- ____ _______ _Length of each line----- Width of trench__a- -__,____________ Type of filter material/ �'f�_Depth of filter material____-/� �f-----Total length___._---�----------------- ' w- Seepage t: Distance to nearest well___.'_ __--------Distance from foundat la_.___.Distan a to nearest lot lin`al_-______.__ Number of pits------/------------Lining material-_ fF/ Sze: Diameter_ .------__-Depth__�sJ_ - ------------- Cesspool: Distance from nearest well-----------------Distance from foundation__________________.Lining material------------ - .___________._ El Size: Diameter--------------------------------------Depth-------------- ------ -----------------------------Liquid Capacity---- ------------------ --gals. Privy: Distance from nearest well----------------____--------------------------___Distance 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 regulations of the San Joaquin Local Health District. (Signed)------------------------- ......--- v -- - ----------- ------ - `------------ By: - -----------------------------------------------------(�or Contractor) Y:----------------------------------------•--------- ----------- ---- --------------------- (Title)-- (Plot Ti+le) - ---- ------- - (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY tl �` t --------- DATE------ REVIEWED // REVIEWED E I IS --- i----------------------------------- ------------------------------ DATE---------------------•-------------–--- i3UILDING PERMIT ISSUED -----------------------------------—-------------------------------------- DATE ----------------------------- A terations and/or recommendations---------------__----------------------- - __ ----- ---------------- --------------- ---- ----- - --------------- - FINAL INSPECTION BY:--- -- - - ---- ----------- - ------------ Date----- ��-tea c - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stroot 132 Sycamore Sfreef 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California r ES-9-2M Revised 8-'59 F,P.Co.