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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 a plication is made in compliance with County Ordinance No. 549. f) �J U o$- C 5-0—1-3 JOS ADDRESSA D Owner's Name_-__-_.- ----•-•, , ¢ ------------------------------------------------------ -------------- Phone.---- '-----(-�- -- v--------------------------------- -°-�--- Address_.... Contractor's Name-- - --- --• ------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence IM Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __f_ Number of bedrooms ---c-.- Number of baths A.___ Lot size ------ '�------------------------------_ Water Supply: Public system ❑ -i!Corri#unity`system P❑ Privafe.R].,Depth to,Wat#r Table 10- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam §d Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes P9 No FHA/VA: Yes E] No ❑ x t TYPE OF INSTALLATION AND SPECIFICATIONS: Se tic Tank: Distance_ from permitted if public sewer is ova_liable within 200 feet.) (No septic tank or cesspool' p nearest. well-4--0 Dista ce from foundation__.._ G Material ------------ �, u No. of`compartments- - "----------------Size- ----- C: _------ _ Liquid depth_..---- ---------- pacitYS' ------- Disposal Field: Distanc'Ofrom 'hearest\well_4_? Distance from foundation_""4PZ----------Distance to nearest lot line----6--_.--_-- CID Numbe of fines_-_ `y '- _ engthVf;each line---_b '___ ' Width of trench_._.__''-`--"-----..---._--..._ Type of filter material_r=�_:r __- DepthofFfilter material._..1 __----------Total length_.__� _0-�________________________ f" Seepage Pit: Distance to nearest well------------------ Distance from foundatio^n�"`�`� Distance to,nearest lot line �1 El Number of pits------ -------------Lining materiaal .__ -____.Size: Diameter-__�- Depth--------- Cesspool: Distance from!;nearest well------------------Distance from foundation--------- material---_____-_______------------------- e� Size. Diameter'_________________________.._.___----Depth.-----=I ------------------------------- -------Liquid Capacity gals. Privy: Distance from+:nearest well------- - ----- `_4. ._. +an—a from nearest buildin ❑ - Distance to nearest lot line-------------- - �._----------------- ---�;•='-'------�------------------------------------------------------- --------- Remodeling - -Remodeling and/or repairing (describe]:------.---------------------__+--------`----- ' � ' _ . I , '"I�t'_'`%A. -------------------------------------------------------- •-- - - - == -------------------- -- --- - $. I I hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin County1 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Si ned I r w { g } �"- �-'-- ------------. . ---------- ------ ------------------------------------ (Owner and/or Contractor) VV �� ' By:--------------;----------------------------------------------------------------L--------------- ------------------------------- (Tale) (Plot plan, showing size of lot, location of system in relation to wells; buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.___ ----------- DATE / '•,r lREVIEWED BY-----'-- !E--------------------------------- --------- ------- -------------------------------------------------- -- DATE-----------------------------------------------------------. BUILDING PERMIT ISSUED----------- -- DATE------------------------------------------------------------- Alterationsand/or recommendations:--------------- ---------- ------------------------•-•--------------------------------------•---------------------------------------------- ...---------- -•-------------------- ------------------------•-----=--- ------------------------------------- -- -------- ----------------------------------- = � --------------------- .�-/ `� - ------------ ------ .G. :.____ = _. .. _ ------------------------------------- - FINAL INSPECTION BY:---- ----- Date '�� - ------ - -------------------•---- j 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 1.57 F.P.CO