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APPLICATION FOR SANITATION PERMIT Permit No. ._1..--..__-.- (Complete in Duplicate) 41 This Permit Expires 1 Year From Date Issued bate 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- Owner's Name---- ___� _a2l.�11 ------------------ Phone-------------------------------- Address----------- +r � -------- - `-------- ------- ----------------------------- Ir Contractor's Name. satmeS.r ------------------------------•-------------- ----------------------------------------------------------- Phone----•--•---•------•--- Installation will serve: Residence .Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Number of bedrooms __,�_ Number of baths _�.._- Lot size 1�C�_��----------------------------------- Water Supply: Public system ❑ Community system ❑ Private-[V Depth to Water Table _10t ft. Character of soil to a depth of 3 fee4 Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam &] Clay ❑ Adobe ❑ Hardpan Previous Application Made: Yes ❑ No ❑ 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.) Septic Tank: Distance from nearest well-_�- -------Distance from foundation---L0_---------Material_._�wvlco (i( -------------- No. of com.partments__.�_____.____'_-___-Size_�_�___ --k_C__.__._-Liquid depth_____ __________________Ca acit Disposal Field: Distance from nearest well. ---- f-.Distance'feom foundation__;Z-O.._______-Distance to nearest lot line___________ Number of -____.__ ___-______ ----77' _-------------Width of trench___ ------------------- Type of filter materia __ / epfh of filter material___f_g?_._____.Total length----` C -- ---------------------------- Se ge Pit: Distance to nearest well-well_ - "___,__...___D,istanc fro fund tion___a`r_o-----------Distance to nearest lot line___± `.___ _._ Number of pits.--��f_ --------------Lining material ` Size: Diameter-_-!33...--------- Dept 07r� : �. Cesspool: Distance from nearest well----____-__--.._-Distance from foundation--------------------Lining material____..-___.______-_.____.___ ._______ ❑ Size: Diameter-----------------------------8-------Depth----------------------------------------------------Liquid Capacity---------------------- -----gals. Privy: Distance from nearest well__.____________.______...___________________Distance from nearest building.----------------------------------------- ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe}:---------------------- =-------------------------- ------------------------------------ ------------------------------------ ------------------- --------------------------------------------------------------- e--------------------------------------------------------------------• ------ - ----- -- --- --- --•- ---------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- ------------•------------------------------- -------------------------------------------------------•-------------------------------------------•----------------------------------------•-------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ! ordinances, Sfatp laws, and rules and regulatiopss of the San Joaquin Local Health District. (Signed) -----------------------------------------------------(Owner and/or Contractor) , By: -----------------------------------1i---------------------------(Tit e)---------------------- - --- ............ ----------------- (Plot plan, showing size of lot, location-of systerim'in relatiowfo wellt.•buildings, etc., can be placed on reverse side). t e I i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ DATE--- REVIEWED BY- ------------------------ -- - DATE BUILDING PERMIT ISSUED------••-------------------------- -------------------- --------------------------------------- DATE------------------------------------------- Alterations and/or recommendations: ------ --------:�-;----_----=------------ ----------------------------- -------------- v -------------- ----------- -- --------------------------------------------------------------------------------------------- ="" `-- ---------------- -------------------- --------- - f ------------------------------ -------------------- ------------------------------------------------------ ----- __j--- ': --------.-.---------- ---------- - -------------------------------- �, -- ------------------------------------------ ., fir♦ , FINAL INSPECTION BY:%'_- '._,_7---- ' --------- ----------- Date-----------------------------} SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised&•59 F.P.Cc. 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