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APPLICATION FOR SANITATION PERMIT Permit No. .1�6.22 (Complete in Duplicafe) / This Permit Expires ] Year From Date Issued Date Issued .%l/y/^_�_. 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 --------------.-pLOF-C�A�TIO-1N--.�_-,n-.--•.-b Owner's Name............ , Address--------- 1 - ------ -------------------------------------------- Ph o.nteer--��--�--- -_ - -•-••- _.. . ..- ----- --• . •r_ . ....f.;S�x�,S..�---•�,r�l� -- c-s�----- --------- Contractor's -- � Contractor's Name------•---- ------------------- ------------------ ------------------ - -- - -------. Phone... . Installation will serve: Residence? Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._..._.-1Number of bedrooms __3__ Number of baths _X-Lot size'._.._. Q_Q :(� ' -- ---------- Water Supply: Public system ❑ Community system ❑ PrivateDepth to Water Tableft. ° Character of soil to a depth of 3 fa t: Sand ElGravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑� No ❑ New Construction: Yes ❑ No ❑ FHA/VA:qYes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:-1- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic.Tank: Distance from nearest Iwell__. }__-Dis XNo. of com artments-.._. " ta'nce'from foundation--.....1-4'.. .Material-.._.-- . Liquid I -- -----• depa h_-._ .- --------Capacity-----IF 0------ Dis offal Field: Distance from nearer well f - ,.��.._:.:Distance from foundation._,Cf2---.._--..Distance to nearest lot line..,:___...-._. Number of lines'.-_ _._ , ` ----- -_. -._. Length of each line _ 6 �D Width of trench---.1 �� Y /lEPlr Type of filter material-__-c�C------Depth of filter material_--.__ -k-_--_._Total length_._... /j,---. Y _ • Seepage Pit: Distance to nearest well __.-.R'_.__._.-_._:Distance from foundation...................Distance to nearest lot line.......---...-_. ❑ Number of pits..________________I Liningcma' dr.' ------------- ------Size: Diameter---------- ----- ------Depth------. Cesspool: Distance from nil ------------------------- Cesspool; `'---�`_Distanc from.foundation'_..-____..___.Lining material.-_.............. .:. C' - --.... hJ� El Size: Diameter. = -'— -------- Dep#h – '--------------------------------- ----- --Liquid Capacity- --------------------------gals. Privy: Distance from neIarest well-�--------- --------------------- ---_ ...__-Distance from nearest building ------------------- ------- Distance to nearest lot line-_,..-____._____ _ ___ ---------------------- Remodeling and/or repairing (descr&)::_-_._______+_e}-------- I -------------------------- --------------------------------------------------------- -------- ------------------------------------------------------------'--------i---------------------•------------------------- --------- I hereby certify that I have pre ar fhis application and that the work will be done in accordance with San Joaquin County ordinances, State laws, d rules nd re afions of the San Joaquin Local Health Disfricf. (Signe4 d) ' * - (Owner and/or Contractor) ter..., ---------------- o of system in [ itle] ------- ------ C_ " y (Plot plan, showing size of I tT locatin r ion to wells, buildin s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY T- '-��--'-------------------- - - DATE------ REVIEWED B?---------------------------------------I -- - -------------------------------------------- .I ----- DATE --------------- UILDING PERMIT ISSUED- ---------------------------------------- Alterafions and/or recommg.ndations:- ° A E. --------- - -------------------------------------- ----------- l l� ------------ - -------------- - ---- ------------- - -- - ----- ------------ ----------- ------ - --- ------ - •------ -. --- : -------------------------------------------- FINAL IN ---------- Date------- ~ � -- - -- - ------------------- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 1 300 West Oak Street 132 Sycamore Street Bid North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California � FS-9-2M Revised$-'59 F.P.Co.