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•G c, �G °r APPLICATION FOR SANITATION PERMIT Permit No. ..)2. . ..:��' (Complete in Duplicate) This Permit Expires 1 Year From Date Issued 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 Ordinance o. 549. JOB ADDRESS AND LO CATION l- ------- - --------- C% _,_e-—----------------------------------------' Owner's Name------ ) ----------- ---- - ---- ---------------------- ---------------------- ----- ---... Phone-------------•------....------------ Address------------- - Contractor's Name r ------------- Phone _ {l' Installation will serve: Residence ® Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.Number of bedrooms_-_ Number of baths _v� Lot size i Water Supply: Public system ®'mmunify system ❑ Private ❑ Depth to Water Table'!7 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [-'Flardpan ❑ a Previous Application Made: Yes ❑ No E4}�New Construction: Yes ❑ No [4---FRA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) is nk: Distance from nearest well-----------------Distance from foundation--------------------Material-------.-----..._-----_-.-___.__......_----_---. No. of compartments------------ -------------Size---_--------------------------Liquid depth--=-----------------------Capacity-----------•--------�- Disposal Fie i d: Distance from nearest well --_.__-.- istance from foundation.,!A0__-----Distance to nearest lot line---15-_______ Number of lines_________ _ _ ______ _ Length of each line------.--- --Width of trench-12-V--- Type rench-12-V--------------------- � T e of filter mate "al - - /Depth of filter material--_ .__ �r -- YP - -- - P ��---------Total length------�-�---�--------- � --- •-- - � � T r Seepage rt: Distance to nearest we __ Distance f~r� fou ation___ ___.__. 'st nc,� to nearest lot line_.-_.^ ...__... p _-Lining material---- / Size: Diameter-- - ------------Depth----- ---* �---_----------- Number of its________ _____ � l� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-.-.--_-__.--____._____._____----.--. a i ❑ Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity----------------------- ...gals. ; Privy: Distance from nearest well----- --------------------------Distance from nearest building.--------.------.------_------_--------.-. ❑ Distance to nearest lot line--------- Remodeling and/or repairing (describe)--------------- \,-r---------------------- ------------------------------------- ------------------------------------- -------------- --------------------------•------------------------------------ = ---•------------------- ----------------------------------------------------------------------------------------- ----- ----------------------------- -------------------•-------------------------------------`----------•----------------------------------------------------------------------------------------------------------------- I hereby cerci y th t I have prepared this application and that the work will be done in-accordance with San Joaquin County ordinances, State awand rules,and egulations Sah Joaquin Local Health District. (Signed)------------ -------- --•--------- -- ------ --------------------- --- ------------ (O er and/or Contractor) BY: --------------------- ----- = ----- - -- (Title) 4 ---------- (Plot plan, showing size of lot, location o em in relation to wells, dings, etc., can be placed on everse side). w - FOR DEPARTME T USE ONLY A F4 APPLICATION ACCEPTED BY-- ._ DATE----- ---- -----'------------------------------------------------- -------�� - -1--- ---��---�----------------- REVIEWEDBY------ -----------------•---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------------------------------------•---•--------------------------------------------------------------------------------------------------- ------------- ------------------------------ ------------ ------- ----- --•---•---------------------------------------------------•-- l�a ----------------- ----- ------- ------ ------------ ------------ ----------------------------------------------------------------------------------------------------------------------- ------------- .............. FINAL INSPECTION BY: - - - - ---- ------ ---------- Date ---- ,�� G (° C3 - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 308 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 0-'59 F.P.Co.