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APPLICATION FOR SANITATION PERMIT Permit No. . .3_ .. (Complete in Duplicate) �� This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descr ed., This application is made in compliance wit ou t Ordinance No. 5 9. —tel. JOB ADDRESS AN LOCATIOpI ------- -- -- --- - -- 1----- - ----- ------ ------ -- -AI p �" D_ Owner's Name- l_.S_�FI -�1C_------ 7-Q.. J4-_--------- s Phone------------------------•--------- Address ( `� - ` Q_ ffY -`-----------•------------ Contractor's Name P �T-------d/V '--------------------------- ---- Phon __- - -�� 477 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----�__ Number of bedrooms __Number of baths _1_____ Lot size Sl1 -_________--____--___..__ Water Supply: Public system [ Community system ❑ Private ❑ Depth to Water Table3.5,ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe ❑ Hardpan E] Previous Application Made: Yes ❑ No 5;L New Construction: Yes ❑ No �C FHA/VA: Yes ❑ No [K TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel#_________________Distance from foundation--------------------Material __-.-------------------------------------------- 0 __-__-___-___-____ _ _______________._____- ❑ No. of compartments---------------------------Size.—_..-------------------------Liquid depth------- ------Capacity-------------_--------- J�y i r Disposal Field: Distance from nearest well._ _ ISDistance from foundafion___.F-L________Distance to nearest lot li e_� _______-. Number of lines___' - �_ _____Length of each line-,to-, ____ Width of trench-�" !� Type of filter material �Qt% .___Depth of filter material_______________.__Total length_________________-QI•/____________-_._ Seepage Pit: Distance to nearest well_ _ ____Distance,. om foundation_ _ �] I r u________.Distance to nearest lot iine__/[Q_.__..... � Number of pits. g t. p .r .�_Linin material___ _ _Size: Diameter_.&W De th�Q____________________ Cesspool: Distance from nearest well----------_------Distance from foundation--------------------Lining material_-________.._________-_______-_._-_. ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity-.-.------------------------gals. Privy: Distance from nearest well-________________ti____._____._______-.________--Distance from nearest building_.___.-__--------________-___-.._--____._. ❑ Distance to nearest lot line.......=--------------------------------------------------------------- ---------------------------------------------------------------------- Remode4ing and/or repairing (describe):- Q � -------------------•--------------------------------------------------- -------------------------•-----------------------------------------------------•---------------------------------- I hereby certify that I have L this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rule an regul ions of the n J 'n Local Health District. ' s r Owner and/or Contractor (Signed) , -------------0----- - -------- ) BY� -------------------------- --- - -- ---- -------- ---------(Ti+le) ------- --- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placeroneverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------ -- -----------------------------(2-'5/' - --- a----------- DATE----------- T ----------------- REVIEWED BY-------------------------------- ------------ ------------------------------------------------------------------------------- DATE------- - ------------ -------------------•---- BUILDINGPERMIT ISSUED--------------------------------------------------------------—------------------------------------._ DATE--- ------------- Alterations and/or recommendations:------•------------------------------------------------------------------------------------------------------------------------------------------ ------------ ----------------------------------------------- -------1-------------- ------------------------------- --------------- ---------------------------------------------•--•----------------------------------------- ------•------- ------.--- ---------------- ------------------------ --------------------------------------------------- -------------------------------------------------------------------•-----•-----...------------------------------- ----------•---------------- ---------------------------------------------------------}-------------------------------------------------------------------------------------------------------------------------------------- Of - FINAL INSPECTION BY:- ------------ ------------- Date-- -- -.(e-1-------------------- 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.CV.