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t i r' APPLICATION FOR SANITATION PERMIT Permit No. ..f,!...... .. (Complete in Duplicate) I y�/s G This Permit Expires 1 Year from Date issued Date Issued ------------ -•- _--c 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, S49.' JOB ADDRESS AND LOCATION- -- - --- / ----------------- Owner's Name--------- -- ---------------------- --------- ----- Phone------------••--------..------•--- Address --- .2e�-z- - ------------------------------------------------------------------ Contractor's Name / �.- �. ----- --------------•---------------- { Phone. ------ r� f Installation will serve: .Residence 0---A' partment Rause ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms --/__ Number of baths __/--- Lot sizeX_.Ls-o-------------------------- Water Supply: Public.system Lj" Community system ❑ Private ❑ Depth to Water Table.-------- ft. Character of soil to a depth of 3 feet: Sand Gravel , Sand Loam Clay Loam P ❑ ❑% y ❑ y ❑ , Clay [ Adobe Hardpan ❑ 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.) Septic Tank: Distance from nearest well"______._______Distance-from-foundation--------------------Material ___._._______________.____-_______ No. of compartments - Size --- = - -Liquid'deptli_--------------- El T Capacity Disposal Field: Distance from nearest well kWistance from foundation___.`---------Distance to nearest lot line_______ [ Number,of IinesY,______ _ Length of each line_____,;,9Q Width of-trench_.�4F_'r Type of filter material____. __Depth of filter material__f _.!r--------Total length____-3�_ ------ Seepage Pit: Distance to nearest well__ __Distanee from fo ndation___,/,P__.___--_.Distance to nearest lot line_- - ___`. _ Number of pits__'_-------------Lining material----QSize: Diameter_ � __----_-_._ ------- Cesspool: --__ Cess ool Distance from nearest well__ _____________Distance from foundation__-____________--_:.Lining material____._.______._____.__ pI"- I ❑ Size: Diameter----------------------------------- Depth----- --"=== - -- ------Liquid Capacity------- -- -gals. Privy: Distance from nearest well________________________ Distance from nearest building--------------____-_____________._____. ❑ Distance.to nearest lot line____t____________.A Y ' Remodeling and/or repairing (describe)-------------- -------------------------------------------------------------------------------- i -------------------------------•------------------------------------------•---- F ----------------------------------- ------------------------------------------------------------------------•- --------------------------------------------- -------------------------------------------------------- 1 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 f the San-Joaquin Local Health District. i (Signed) ---------•-- ------------------------------------------- --------------------------- (Owner and/or Contractor) s By:-------------------------------------------------------------------------------------------------=------------------ (Title)--------- ----------------_--- - -------------------------- E (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 44 ' FOR DEPARTMENT USE ONLY 4 1 ' APPLICATION ACCEPTED BY-- '--------- -------------------------------------- DATE----- REVIEWEDBY ------------�--------------------------------------------------------------------------------------- DATE ` !i BUILDINGPERMIT ISSUED-------------- t--------------------------------------------------------------•--- ----------------- DATE------------------------------------------------------------ { Alterations and/or recommendations:---»___--------------__________�__.__ ; .------__-- 1- = ------ -------------f-7-----------CI--------- ------ ------------ ----- ------ -- -- - --- -- ----- ---- ------------ --------------------------------------------------------- -.----- -------------------------------- ------------------------------------ FINAL INSPECTION BY: -------- ------------------ Date-- ------------ .. ". ..` --------------------------- SAN V--SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amorican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.Co.