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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 Ordinance No. 549. ADDRESS AND LOCATION 1 - ------------------ JOB - - - ��4II Phone_ Owner's Name--------- - ----------- --------------- ----------------------------------- ----- ----------------------------- Address___._ _ r - ---- - - - -- -------------------- -- r 01--- ---��-- ------- --------- Phone_ _ Lz. ✓ L� 7 Contractor's Name__.-___ � - Installation will serve: Residence F1 Apartment House El Commercial .[3 Trailer C urt ❑ Motel ❑ Other Number of living units: -------- Number of bedrooms -------- Number of baths e .-_��. Water Supply: Public system ❑ Community system ❑ Private Rk"6epth to Water Table-/e_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made:. Yes ❑ No B---New Construction: Yes Rr__No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND1SPEClFICATIONS: . (No,septic:.tank or:cesspool permittedrif public sewer is available within 200 feet: -- c -- Septic T k: Distance from nee est welj� .._- i Distance from f�ouu dation _ 'F--------.Material - No. of co apartments----- :e 'er Size"_ r Liquid depth Capacity .. ` Dispose field: Distance from nearest well�°AO---------Distance from foundation__t _S.........Distance to nearest lot hse__ .______. Number of lines--------- ---------.------- ---Length of each line------ ; --- Width of trench----Rlflo__F_.. .------------ � { -----Total length --------------------- Type of filter material_J�i �_Depth of filter material-----�,8----� g � - Distance to nearest well_ ___-_-___Distance om undation__ 16----_"_...Distance to nearest lot Seepage it:_ _ Number of pits.------J------------Lining material _-- ------°""----Size: Diamete ---------------Depth--[ .�------------ ----- Cesspoo` I: Distance from nearest well_________________Distance from foundation_____-___-"- -_---Lining material------------------------------------- Cesspool: _ -..""""__-"_"----"".-____""""--"" ❑ -----.Depth----------------------------------------------------Liquid Capacity------------------- gals. Size: Diameter------------------------- Privy: ) Distance from nearest well----1- ---- --------------------------- Distance.from,nearest building------------------------------------------ Distance to nearest lot lire-______._.___ " + Remodeling and/or repairing (describe):_.___ 7. 1I ;� �,_J ------------------------------------------ ------- -- --- r -------------------==------------------------------------------------------------ --------- i I I hereby certify that!I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St aws, and rules regulations of the San Joaquin Local,Health,District.r.r.� F. ° A�4------------- Owner and/or Contractor) (Signed) ` 0. ' .t B a / --------- ------(Title)--- _ (Plot plan, showing size of lot, location of system in r a ion to wells, buildings, etc., can be placed on reverse side. t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------ -- ----- ----- DATE REVIEWED BY -- DATE - BUILDOG PERMIT ISSUED------------------------------------------------------' ''- DATE Alterations and/or recommendations:--------=--------------------------------------�'----------_---------- - { -------- -C P„1 C4kA �s� ----- - - --- "--" �---- -------------- j� I iy -----• .�S/- -y----' """'---'-f-----------------------------_-------------------------------- -_._ F FINAL INSPECTION BY:------- - - ----------------------------- Date- o 711>2---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California .,.,,,. .Manteca California Tracy, California ES-9-2M . - Revised 1.57 F.F.CO. .