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APPLICATION FOR SANITATION PERMIT Permit No. .j...............:L (Complete in Duplicate) Date Issued J_"`__ _.C1 - This Permit Expires Z 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 described. This application is made in compliance with County Ordinance No. 549. 01�JOB ADDRESS AND p LOCATION _ Owner's Name_ _!!u'_.t , ---------11--0911-1-114-------------------••- -------- ----- -- ------ ----------------------------------------- ----------- Phone------------•----------------------- Address---- ?° - ---- ------------------ -- •------- ------------------------------------------------- •---------------------••-----•-------••--•--••---------------- Contractor's Name -----------------•--------••--------•---------- I --------------- Phone-------•---------------••--------- Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --__ Number of bedrooms -'3-- Number of baths ---I--- Lot size b_ ___I Y_0- -- - ------------------------ Water Supply: Public system OR Community system ❑ Private ❑ Depth to W�ter Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam,] Clay Loam ❑ Clay Adobe ❑ Hardpan,g Previous Application Made: Yes ❑ No New Construction: Yes J No ❑ FHA/VA: Yes ❑ No ❑ I .TYPE pOF INSTALLATION AND SPECIFICATIONS: N septic tanvor cesspool permitted if public sewer is available within 200 feet.) WspoDsal ark. Distance from nearest well_________________Distance from foundation____._______._____.Material---------------.--------------------------------- No. of compartments--------------------------Size--------------------------------Liquid depth---�-- --Capacity----------------------- Field: Distance from nearest well..s_0P-'__Distance from foundation---30l------Distance to nearest lot line____-__- Number of lines- ._-�__________ _____ Length of each line-----J® -__-_._._.Width of trench._.I-_'V__``__---------_______._ Type of filter materiaDepth of filter material___._ -_----------Total length- A------------------------------- k-----Di ----•_________________---_--__ See age Pit: Distance to Heaves well___ _______ Dista ce from foundation___ ________ ____Distance to neare lot line.__.._ Number of pits- _____________Lining materia _______._Size: Diameter --_...___Depth___.____-_____---_ f i Cesspoo : Distance from nearest well-----------------Distance from foundation--------------------Lining material____.___.______._.._____----------__. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity=---------------- ----------gals. I _._-_._Distance from nearest building Privy: Distance from nearest well------------------------------------ ----- 9 ------------------------------------- F1 --------------------------- - ❑ 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, a rules and regulations of the San Joaquin Local Health District. ' ------- --- (pot 0 -- --------------- ------------------ wner and/or Contractorl � Signe -------- _.. - -- B - -- ----- -- -- -�' - "- tTitlel -----------' " `-d�---' - . . Y:---------- - – (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 ACCEPTED BY_;- - -- ---- ------------------------------------------------- DATE--- ------- ----- REVIEWEDBY------------------------------- ----------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------------------------- -•------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------- ----------------------------••----------------------------------..-..-•--••----....----•---•-••-----•------------- I . --------------- - -------------•--------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------•---------------- -------------------•-------------•----•-------------------=-----------------------------•--------------•---------------- •---------------------------------------------------------------------------------------------------- .. i FINAL INSPECTION BY:---------- -------------------- Date_._.- _._/ .._�� ..._. -------------------------- I 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 FS-9-2M Revi,, '59 F.P.C..