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APPLICATION FOR SANITATION PERMIT Permit No. kk (Complete in Duplicate) (Com P Date Issued ------------------- A ----------------- 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. A JOB ADDRESS AND LOCATION i -- --- -- - -------------- Owner's Name------------�' <,� ----- " _:� :".. �. . Phone ?- — �. ...-_£�_--- Address............................................................ % ........ -------- .------ - ` ----'`'-=------------................................................ Contractor's Name..... •---••------•-•---- i' ' .+1_ Z1'___._(_�,1 `-- -----------------------------------------.. Phone................................... Installation will serve: Residence Apartment House ❑.ltt Commercial E] Trailer Court ❑ Motel ❑ ( _'Other ❑ Number of living units:)_'_._ Number_of bedrooms _.___ Number of baths _�.... Lot size - I- ._+ __X•__C_t� __________________________ e ..__.. Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe% Hardpan ❑ „ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No 171 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ,l Septic Tank: Distance from nearest well_____. ......Distance from foundation----L C_.____---Material..... "_:' = No. of compartments_._- ----------------Size._`1.(;.-..........` -Z. ...___Ligwd depth..__" L-----------Capacity.. a M-_---__- �' 1k Disposal Field: Distance from nearest well ._ ____Distance from foundation___r__j_____ ______Distance to nearest lot line____-_S _.._. Isf Number of lines-------I_______________-__-___--Length of each line-------- --------------Width of trench---2,.*P-___.-_._____-____ Type of filter material_1tIlk-------------Depth,of filter material____- _______Total length-------_------- .__�---.--_----.--_ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line__-___.-__--__-__ ❑ Number of pits----------------------Lining materiak----------------------Size: Diameter-----------------------Depth_-.____-_______-.--__.________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------------------------r- ❑ Size: Diameter------------------------- ------Depth---------------------------------------------------Liquid Capacity--------------------------..gals. Privy: Distance from nearest well-------------------------------------------------.Distance from nearest building------------.-----------------------_-_._. ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairingfts.cr )e):__- _ -----._ ---_--- --• __-----�rt �'^ '�-%' - < 9 rs� n ccS `� 1^`'----•-------------------------- --- -------------------- ---------- -------------------------------=---------------------_------------------------ --------------------------------------------- ------------------------------------------------------- --------•------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that 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 Local Health District. (Signed)- ----------------- ---- ---------- r ----------- ---- ------ ------ ---------------------------------------------(Owner and/or Contractor) 40e BY� 1-=c`=... ------ -- ---`------�----------- ------------- --------------(Title)--------------------------------------------------------------- (Plot plan, owing size of lot, location o , ystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY Zr APPLICATION ACCEPTED BY------------------ --------------------------------------------------- DATE--------�'----g-- -A)-------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------_----- DATE-----------------------__--------------------------------- Alterations and/or recommendations- ---------- ------ - -- ------•••------------------------------------------------------------- _c" - -- - - - - - ----------------------------------------- - i^^ s �� Lsn s r _c" s----------- -------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------- ------------ FINAL INSPECTION BY:. 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.