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APPLICATION FOR SANITATION PERMIT Permit No. ��/' (Complete in Duplicate) �i �� Date Issued Application is hereby made to the San Joaquin Local Health District for a permitk",struct and install the work herein described, This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION `------ - = � j'----•--•------------- i --------- Phoney f1 Owner's Name �� Address........•-'------------------------------------ --- - ------------------------- -------------•-------- Contractor's Name-#--------•-------•------- - 1 - - --------- Phone��___ .TM , i { I [ Installation will serve.: Residence [��partment House ❑ Commercial ❑I Trailer�Court I❑ Motel ❑ Otheri❑ I Number of liling units: _ .___ Number of bedrooms _e-_ Number of baths _,�__ L size____,� -.�- `'_____________________ I �. Wafer Supply: Public system ®Community system ❑ Private ❑ Depth. to Water Table -5- ft. `- Character of soil to la depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay ❑ Clay ❑ Adobe® Hardpan ❑ Previous Application,,Made: Yes ❑ N -.[]5,--N.ewwConstruct,ion;_Yes_0 No ��H�°.Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if-public sewer is available within 200 feet.) t S fit Distance from nearest well___#^ -------Distance from foundation--------------------Materia4---------------------------------f_._._:__._. No. of cornpa.rtmen'Fs-------- /------�KSize-------------------------------Liquid depth------------------------ Capacity-}--------'----=----- . _ _____Distance to nearest lot line_'�Q.f_ IF Disposal Id: Distancefromnearest w it -__ '``:`Distance from foundation_ ---- Number of lines_____ _____ ________ ______ _Len Length of each line______ ----__._____.Width of trench._____ { _Total len ` Tjype of filter materiaI__�_______.:_ __ -Depth of filter material___________. length ________________________ ' Seepage : Distance to nearest�/well_ iq�'_Distance m f undation___ I _ __._.Distance to nearest lot Number of pits----:-!'---_n________Lining material/ 's.%__.Size: Diameter_ .-__ Depth c _________________ I Cesspool: iDisfance from neare vye l,---- ___:__-Distance from foundation--------------------Lining material---------------------------01:.-------- L1 _ ___- Size: Diameter_- ----`------------------------------De th---------------------------------------------------Liquid Capacity -- I Privy: Distance from nearest well----------_---------------- ---------------------Distance from nearest building-------------------- -________.___.____-- ❑ Distance to nearest lot line------------------------ -- ----------------- ------------=---------= -------------------------`---------------------- -•----------------•-- r - . Remodeling and/orjrepairing (describe):_-_____________________ � _______ _ f `-------------------------------------------------•----------•------------•---------------------------------•---•-------`--•------•-�---•---- --- -- ;r- l k = ' I hereby certiN that 1.have.prepared.fhis appiication.and fhaf-fhe,work_will be done in' accordance with San Joaquin County ordinances, 5 t laws, an u s and regulations of f an Joaquin Local Health District. (Signed) - --- n_._-------------------------------------------------- ____Owner and/or Contractor B ' (Teale) Y ---------------------- (Plot plan, showing size of lot, ocation of system in.r tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------- --------------- -------------- -------------------------------- DATE------------------ ---_ ------ BY --------------------------------------- - ----- ------------------------------ DATE----------- -------- - BUILDINGPERMIT ISSUED--------=----------=--------------------------------- - ---- ---------------------------- DATE---------------- -'--- ---------------------------•------ Alterationsand/or recommendations:------------------------------------ -- -• --- --------------------------------------------------•------ --•---------------•--------•----•--------------- --------------- --••---•------=-------------------------'--------- -- ---------- ----- --------------------------•--------- -•---•----•--•--------------------------••-•-------------------- -- ---------- ----------------------------------•-----••--- .....---..._.-_._.--..-------------•---------------•----------------- ----------------P - -- - - --.------------------------------- ----- --.--.------------------------------ ----- - - �:..--.---- -.--.--------.-�--------------.---------- ----------------------- --------------.-------------------.-------------.------------- 44 FINAL INSPECTION BY:-- ----- -•------ --=-------- ' Date_-. --- - -=------ -- 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 Revisep ;-57 F.P.CO.