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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ------ 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�Ordintrice No. 549. i JOB ADDRESS AND LOCATION__�I(_- _ ---- --- - _- _ � ----Qt4----------=A',1.a� - .Owner's Name----- - -- -------- • ------ -- µ --------•--- Phone.------------------------- Address ------ ------ -- _ - ,- ."----------------"-------------------•------•---•-- ------•-------- "------------------- ------- r� �_. Contractor's Name -- .. ------ Phone Installation will serve: Residences2'_A�partment House I] Commercial ❑ Trailer Court ❑ Motel ❑ Other [] Number of living units: __/____ Number of bedroora' J__'Number .of baths _/ _ Lot size Water Supply: Public system ❑ Community system 92'0'�Frivate .❑ Depth to Water Table'- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay.[ Adobe Rq-11ardpan ❑ Previous Application Made: Yes ❑ No VT`� New Construction: Yes Rg-'No ❑ FHA/VA: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__.` -------Distance`from foundation-__l --------.Materia----f✓(,�' --- - ------------ No, of compartments_.__._._. Size_xd6-x---!w-___Liquid dep`h."__' '_____________Capac:ty___ _. ©__._. Disposal Field: Distance from neares well__;_-" -Distance from foundation--- p_--_.._._Distance-to nearest lot line_--„j__V____. ®� Number of lines_______ _________-___ ------ Length of each lin e__-__ �/ Width of #Tench___.�'�- `e --------•----•--•_-- Type of filter material_` P Depth of filter material__/�_____--_--."Total leng#h----/.2__--,P------------------------ Seepage Pit: Distance to nearest well----- ^------Distance fro m fou at'son_- p._.__-__.Distance-to nearest lot line._.lQ..____- it .-._-.-Linin material/�. __._______. ize: Diameter-J.?"-.--- __ ®� Number of pits----.�__, g ------.Depth----��-r-------------------- I Cesspool: Distance from.nearest]welly-___--'--,Dista ce from foundation------------.-------Lining material_".__-_._-_________________________ ❑ Size: Diameter----------- -----:Depth--------- -------------- •--------------------------Liquid Capacity--- ------------------------gals. I Privy: Distance'from nearest well ----".-----."..fa`_----------------------------Dista.nce from nearest building--------------_____---"--__--_-.--"-.._._. ❑ --Distance to nearest lot line------ ---------- --: - i 1 i Remodeling and/or repairing describe� - � . - ----------------------•--------------------- ------------------------------------------- •- ---------- - -- --� ----------a =--°-- - -- --------------------------------------------- ------- --------------- ----• i ---- --------------------------------•----------•-----------------------=-------------------- - --------------•-•-•--•-•-----•-----•--"----•"-------------------------------------------------------------------------- ------------------------------------------•-----------•--------------------------•--------------------------"----------------------------------•------------------------...-------------------------------•---------------- I hereby certify that I have prepared this application and that the work will 6e-done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the-San Joaquin Local Health District. (Signed)----------- By: -------- (� Contractor( By---------------------------------- -------------- ---- - - - (Title)--'-- i (Piot plan, showing size of lot, locati f system in.relation to wells;:`,6uildings, etc., can be placeid on reve06side). ~ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. - ----------------- •----- DATE_ ..�----•---•---- ---------------------------------- REVIEWEDBY------------------------------- �` .-------------------- --------------------------------------------------------- DATE--- ---•----------------------------------------------- BUILDINGPERMIT ISSUED-------------- - ----------------------------------------------------------•------------------- DATE-----�---- ------------------------------------- Alteratio s and/or recomme dations: ____._._. rr _ -----------------------------------------------------------------------------------""- - -6k4 � Qk ��-------�------- -- — --s`-'-------- ------------ :-------------------------•-•---•----------------------------------------------------------------------- ---------------------------------------------------- ---------------------•---------------- = ---"---------••----•------------------------�- ------�-°------------------------------------------------------- ---------------------------------•---------------------------- ---,------------------------------- 4 FINAL INSPECTION BY: ----- ` � Date ---------------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street 1 Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , 'Revised 1-57 F.P.CO. rl