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i APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued : t 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 Ordin nce No. 549. JOB-ADDRESS AND LOCATION - '-✓._!�- " ' '� '' w -- ---- ---------------- ------------------------ Owner's Name --- ------ -----------------•------------------------ --------------- - ------------- - Phone------------------ Address------------------- - ... ----------- -------- -------------- ------- '------- ---•----------------••-----•-=---------- --•-•-•-------•----------_-----•--------•----:•-------- Contractor's Name { ---•-- Phone-------------------------i - -- ------- -------------------------------- ----------- - -_----------------------- Installation will serve: Residence T4,, . partment House ❑ Commercial ❑ Trailer. Court❑ Motel Other ❑ Number of living units: ----�__ Number of bedrooms ____r __ Number of baths __._�__ Lot size _____ __________________ Water Supply: Public system"❑. Community system ❑ .Private [ ` Depth to Water Table _ _-__ ft.` l Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ElClay Loam ❑j Clay E] AdobeV Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction:G�CP Yes No 1771 F A/VA: Yes E] No x TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or'•cesspool permitted.if public sewer is available within 200 feet.) +2.� SeptinField: Tkr Distance from nearest well______.._^------Distance from foundation_�y"_-_'__..___,_Material_________________________________________________ o. of compartments------------------- = Size------------------ ----------Liquid depth---' - Capacity_--------------------- No. istance fromnearest-,well-`,2p 4 4Disfance from foundation__-#I '.Distante to nearest lot line_._2._0__I°'umber of lines_._.______1____.-_'___________ __Length of each line___' tZ_ Wid#h of.trench____ype of Vter material_._ > -Depth of filter material__.f_ __-_ _r_Total length______._Y Weepage Pit: Distance to nearest well= a__ "_-`p{stance from_f o dation___......Q____- Distance to nearest lot line_A10__'4'. ! of pits- ------------ g ry material�_p-------- -- - meter.--'•-�-•/- --------,Depth,-- ---- - ---------------- Number p Linin { r _ Cesspool: Distance from nearest well----------------- from foundation-----------------_Lining material________-__-_______-______-_______•_- ❑ Size: Diameter------------ - ---------._:_Depth-----------------------------------------------------Liquid Capacity-V--._ --------- --- gals. Privy: Distance from nearest well_-----------------------______.__ ._ _ ._Distance from nearest building_- _ ------------------------------- ❑ crest lot --'`----.r..----------------- ------•---------------------=--------------------------------------- =--- ------------ ----- f�Distance to ne E 1 i + Remodeling and/or repairing (describe):---: ---lE r=_-- --, - _ .b__ '`----- -------- - ------ ------------------- ---- _ ,F - f r ..� �• E h ______ ___ ______ _ ' - ___________________ _____________ _________ ____.__-____- _____.___ __ I hereby certify that l have prepared this application and Lthaf the work will-be cloneinaccordance with San Joaquin-County ordinances,Itate laws, and rules and regulations of the San Joaquin Local Health District. I s r (Signer---------- E��'� - = {Owner and/or Contractor) �. By-------- '--------__.............. ------------------------------------------------ (Ti+le) ---------------------------------- _-------------------(Plot plan, showing size of lot, location"of system in.relation to wells; buildings, etc., can be placed on reverse side). FOR DEPARTMENT-USE ONLY aAPPLICATION ACCE=PTED BY--- ------------------------ -- ---------------------=--------------------- DATE.................................. ......--•----------•---- REVIEWED BY--------------------------------------------- -'-------------------------------- '-- ----- ----. DATE----------I; __�- w - _0 DATE------------------------- 3UILDING PERMIT ISSUED ---------- , Al+erations and/or recommondations:_«_-�--------- --------------- -------------- -------------•----------•-•------------ --------------=-----------------.11------ s --_____..__e___ -- -- -_-___________________________________ _ -_-_____-_-_______-_-_____.___,_______-____ w i _____________________________________________________ ____________________ _ _ __ _..__________. -____..____________.._.__----_--______.._______._________________-__________ FINAL INSPECTION BY:. ------__-= = 4 '`. Date_:: SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manteca, California Tracy, California J# r ES-9--2M Revised 1.57 F.P.CO.