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to 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 Ordinance No. 549. JOB ADDRESS AND LOCATION--------&-�� y. Q?/t -------- "_`-`- ------------t---------------------------- ----------------------------- Owner's Name----------------2k 1.C�✓ ------• ---------------------- -------- ----{ - ---------- Phone--------------------------------•--- Address----------------- ---- ----------------------------------- ------------- j --- `� - `- -- 4 ' 4 Contractors Name----------- .`----- ------- -- ----------, C/�---- - ---- - - -"----- ---------- ------ -------.Phone----••------------•---------------- Installation will serve. Residence A artment House Commercial (Trailer Court Motel p ❑ ❑ ❑ ❑ Other ❑ Number of living units: Nuniber4 f bedrooms _1 'Number of baths,}._y___ Lot size _f __ __��------------------------------ Water Supply: Public system E] Comm unity system E] Private [�bepth ,� ater Table __gaff. Ai Character of soil to a depth of 3 feet: Sandra—vel C� ❑� Sandy Loam ❑ Clay�Loam ❑ Clay ❑ Adobe Ero�lardpan ❑ Previous Application Made: Yes ❑ No New Conssfruction: Yes,(]—No J2-- FETA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: �""" (No septic tank or'cesspool permmitted if public sewer is available wifhin 200 feet-) b epti Tank: Distance from ne-d°rest well_________________Distance from foundation____________-_____.Material______-._-____. ------______________._.________. t No. of com artments--------------------------Size-------------------- Li uid de.th----------------------_�_Capacity.-------------------_ _ _ q s_» .� � E� i Disp sal ield: Distance"'from nearest well_..�_Q--------Distance from foundation----AP --.---.Distance to nearest lot lir<�_� :---- J Number of4es------/-------- -------- -- Length of each line----- f� Width_vyf�treench----- '�__---------=-_----- 7 Type ofite material XIM ---Depth of filter material____-�8 dotal lehgth =ir_ _____________________ I Seepage Pit: Distance to nearest well_____._.____.________Distance from foundation--------------------Distance toynearest lot line_=_______--__-_-_ \ ❑ N;ber of pits----------------------Lining material---------_-------------Size: Diameter-----k_________-------D;pih_-_---------#__-`--:------------ \ Cesspool: Distance frog nearest well_________________Distance from foundation._.__________.____.�ining material-------------f/____._______________. ❑ Size: Diameter-------------------------„----------- Depth ----------------------------------------- quid Capacity----f gals. Privy: Distance from nearest well------------------------------------------------- from nearest building__;__�___________.__________- ❑ Distance to nearest lot line :�.. = ---------- --------------------------------------- - ----------- - Remodeling and/or repairing (describe)----------------- ------------------------------------- ------------------------------------- -------------- --------------------•------------------------=----------------•-------------------------------------------------------------_' ----------------------------- ------------------------ 1 hereby certify,fhat I have prepared this application and that the work will be,done in accordance with San Joaquin County ordinances, State laws,--and rules and regulations of the. San Joaquin Loc'al Healtli"District. (Signed)---------- �. -------------- -- --------------- ---- ---- -- -- - -------------------- ( W#or Contractor] By: ----------------------------------------- .,,--��------------------------------(Title)--------�� -------- - ---------------- (Plot plan, showing size of`lot,location of stem in reella�tion to wells, buildings, etc., can be placed on reverse side). `FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- -------- ---------------------------------------•---------------- DATE------------ ---A-----° REVIEWED BY ------------------------------------- - = -------------•----------- ------------------------ DATE---------- ------------I---- BUILDING PERMIT ISSUED.••- -------- = -----V------ -I- I----------------------------------------------------- DATE---------------- Alterations and/or recommendations:- (-- - -------" -------- ------- -----------------------•----------------------------------- ----------•--------------------------- ----- -- ----------------------------------------------------------- ------------------------------------------------- -- -------------- -•------------ - ------- - ---- ---- -----------------•----------------------------.._.... J F._ rt --------------------- FINAL INSPECTION BY.-_ - -__ - - 1 - -- ---- Date-- --- -- 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.