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------------- ._-_1 APPLICATION FOR'-SANITATION PERMIT Permit No. -- // � (Complete in Duplicate} pate Issued ---- - 1111__ � '?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 Ordinance No. 549, t ----------------------------- -------------------------- ----------•--------------------------- JOB ADDRESS A D LOCATION___-- _-__- ------ Owner's Name Phone-- .-- Address l 2 �� - ......� ----- -- -- -- - ----------------------- -------------• ------------------ ,--- ---- -- ------- Contractor's Name-- --- _- -d - -x-----•-------..Phone_ _ _ . ' - -•- Installation will serve: Residence ® Apa ment House ❑ Commercial ❑ TrailerCourt ❑ Motel ❑ Other ❑ Number of living units: _-]___ Number of bedrooms _-a-- Number of baths ---/-- Lot size ----�.�_�_�-`lQ � ----------------- Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table ;L a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam.❑ Clay ❑ Adobe ( Hardpan ❑ Previous Application Made: Yes ❑ No PS New Construction: Yes No ❑ FHA/VA;-Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well-----------------Distance from foundation---_---------------Material-------------------------------------------------- o No. of compartments-------------------- ----Size---•-----------------------:---Liquid depth-------------------------Capacity-----------------------� DispWl Fi d: Distance from nearest well------------------Distance from fcundation--------------------Distance to nearest lot line----------------- a ] 40 --------�Length of each line-'---`--- of trench----------------------------------- Type -------------=------- ----- Number, of lines------------------------- - ------ Type of filter material-------------------------Depth of filter material----.------- ---- ----Total length--------------------.•-.-_______•------.- a� .. / . _ Seepage.Pit: Distance to nearest well-_� O/�r a-Distance from f ndation-- - ----------.Distan��to nearest lot fin je- Q_ -.-- I /�� -3 3 ---De tn- S Number of 'its----_:/-____-------Lining material--/ ---Size: Diameter------ p _ ---------. Cesspool: Distance from nearest well----------------Distance from foundation-- ----------------.Lining material-----_---------_-_-.--._----------_ ❑ Size: Diameter-------------------------------------Depth-_-------------------------------------------------Liquid Capacity----------------------------gals Privy: Distance from nearest well----------=------------------------------ --- --Distance from nearest building-----.-------------------------------.-. ❑ Distance to nearest lot line------------------------------- - ------------ i Remodeiing and/or repairing (describe):_- -�� ----- — --4 -------'------- ------------•---------------------•--------•--------------------------- --� ---- ------------- ----------------- ' ----------------------------------------------- -----------------------------------------------•------------------. ----------- I hereby certify that I have pr pa.ed this a plicafio nd t t the work will be done in accordance with San Joaquin County ordinances, State laws a d rules /i %regulatio, of A San J quin Local Ith District. Si ned r------ . ,--__-- (Owner d/or Contractor] { 9 } ��--- ---_ - -- rBy:------ -------------------------------------(Title)-- -- ------------------------- (Plot plan, showing size o 1 .r ion to wells, buildings, etc., can be `prced on reverse de). FOR DEPARTMENT USE ONLY I _ DATE-------- -�' 1 APPLICATION ACCEPTED BY - DATE . l REVIEWED BY----------------------------- BUILDINGPERMIT ISSUED-------------------- -- ---------------------------------------------•--------- DATE Alterations and/or recommendations:---- ------------------- ------------------------------------------------•-------------------.•..._....•-...----------------------: ------------------------------ � �- ------� -� " ------------------------ ---- ----- - - --.--•--------' //`/ f FINAL INSPECTION - Date------1 fl'J ----------_----------------------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Sycamore Street 814 North,-,'C" Street et 300 West Oak Street Y -- Stockton, California Lodi, California Manteca, California Tracy,yCalifornia 1=5-9-21x1 . Revised 1.57 F.P CQ.