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APPLICATION FOR SANITATION PERMIT Permit No.,�11___. (Complete in Duplicate) Date IssuedY `� Applica{ion is herebymadto 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 549. JOB ADDRESS AND LOCATION---- Owner's Name-•--` _ I------------------- l ---------_---- Phone---- --- Ct, +� s�C�`- ------ - Address---------------------•- --------••--------------- --- -----------I------------- f Contractor's' Name-----= -------- +r�fi°Y ------- �1�'� ------ Phonc l7 4107--- Installation +P0,7 Installation will serve: #Residence $t Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel ❑ Other ❑ Number of living units: __1___ Number of bedrooms _`YNumber of baths ___/__ Lot size -----�_0_-_A----/ __'"__.___-__._ Water Supply: , Public tem 9Communify system E] Private E] Depth to'Water Table /oft. ' Character of soil to a dsysepth of 3 feet: = Sand ❑. Gravel ❑ Sandy Loam ❑ Clay oam ❑ Cla ❑ AdobeVL Hardpan E]Previous Application Made: Yes E] No JL_New Construction: Yes El N0 ❑ TYPE'OF INSTALLATION AND SPECIFICATIONS: A�4�� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se ic' T nk: Distance from nearest well--------_--------Distance from foundation-------------------.Material______-i-----------------.-_._________._______- No of compartments-------- ------ -.__Size--------------------------------Liquid depth------------------------lCa acit Dis salield: Distance from nearest well_' —'' "'--.Distance from foundation____________________Distance to nearest lot line------- -�_' Number of lines-----€•-------------------- -`__--:Length of each-line-------------------------------Width of french-------_--------------==__.--�- Type of filter material-------------------------.D.6pfK of filter -ma#eiial-----------------------Total length-!----------------------------------- See ----_----------___-----= --- Seepage Pit: Distance to neare t well IF ___._Distanc .fr f ndatio�_=_1 ______.Distance to nearest I t iine_-/ .-Number of• ifs-- --.---_-_____ Linin material_ __.Size: Diameter___ ��____.De th___ r_______________ rP 9 F cc p - s ,y Cesspool: Distance ,from nearest weld_______________`Distance from f'undafion____________-:_.___.Lining material___.___:.`__________________._------- ❑ Size: Diameter---- :--'----------------------I-----Depth--------=---=------- ---- Liquid Capacity-------=-------------- gals. 1 Privy: `Distance from nearest well------------------------------- - ---------Distance from 'nearest building_ ----------._______________-__________El . '_"_ "Distance to nearest.lot line -= -•-------------- -- --------------- ------------------ Remodeling and/or repairing (describe :--------------I-----------` == ,_ s ---- -------•-=-------------- = --------•---------------- :. - sa r -- i ---------- I 1-hereby certify that l , ave prepare this applic do and that the work will-be done in accordance with San`Joaquin County ordinances, 'State laws, an and re la#' ns of'f San Joaqui Local Health-Disf 'cf. q 4 t (Signed)------- --------- --- le -.1d, Contractor Y -- -.------------------ - ------ - ------- ------- ------ -(Tit (Plot plan, showing size.of_lat, lacafian of system in relation t s, buildings, e ., can be placed on reverse side). I FOR DEPARTMENT USE ONLY f APPLICATIONACCEPTED BY- ---- - -----------=--r-----=------------------------------•---------------•--••------------ DATE-�------------------------------------------ ------- REViEWED BY -- ----------- ------------------------------•------------------------ DATE ' BUILDING PERMIT ISSUED. = ' -----`-•------------------------------------=----------- DATE------N- ---------------------------------- -------------------- Alterations and/or recommendations: = .... = '---•=------•------•---•-----`----•--•---_----•----------------------------------------•------_______•----•------------------ f _________________________________________'--------.------------------------------------------------------------------------------.--------------------------------------------------_______________ _______________________________________._________________-._._____-_____-__-__.______--________.__-______ ______________i_____._ ` ' f _______________,_________________________-._.__._.._____--.___-____-_ ----- ------ --------- . _._._______________________________._--..-__ ___.__ _ _______-_________.______.____._______________________--- FINAL 'fNSPECTION-BY:_.. --- ---- A----M------------- Date_*_.-.-V------ 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 W-2100