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APPLICATION FOR SANITATION PERMIT Permit No. 0: " (Cople ' n Duplicate) 4r Date Issued _1 — C) 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�J--__ ---_. , , ---- ----------------------------------------------------- ---------------------------------------- i ry Owner's Name d¢ ------------- f ------------------------ ---- ------------------------------ - P� 7d �1 Address• - ----- ------------------------------------------------------------------------------------------ --------------- ------ Contractor's Name_-- 1 , ------------------------------------------------------------------------------------------ Phone,1_._'f_'_-_�;_01 Installation will serve: Residence ©- A"partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _ Number of bedrooms _ __ Number of baths size ____-__�'�?_x 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 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or'cesspool permitted if public sewer is available within 200 feet.) Septie ank: Distance from nearest well_________________Distance from foundation---------------------Material w No. of compartments--------------------------Size--------------------------------Liquid depth------------------------ Capacity DlNp s Distance from near well �_._Distance from foundation____, �____-Dist r q, nearest lot line_ r■ wAq • Number of (fines____ --- -__ _-____Length of each line___�Gt __ at Type of filter material------- _-Depth of filter material____._'(_______-__Tota , t! Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance ❑ Number of pits______________________Lining material-----------------------Size: Diameter----------------------- Cesspool: ___-__-_-____-__ - _ _Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining (^� 171 Size: Diameter------------------------------------Depth---------------------------------------------------Liquid Ca -------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building --7:a"- ---------------------------- ❑ Distance to nearest lot line " - -- ------------------------------------------------- Remodeling and/or repairing (describe):---------------------- --------------------------------------------------- -•---.1�-------------------------------------------------------------- •----------------•--------------------•---•----------------------------•------------------------------•----------•------------------------ F _______________________________________________•___-_-._-____•______-____________-___•__-_____. ----------------------------_------------------------------------------ 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)------- — - "'---------------------------------------------------------------------------------------------------(Owner and/or Contractor) BY: ---------------------------------------- --------------------------------------------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_________________-__ ----I ----------------------------------------------------- DATE----------------- REVIEWED BY ---------- ---------------------- � x `' -- --------------------------------- ---- . DATE--------=- 1�--------------------------------------- BUILDING PERMIT ISSUED ------------------------------------------.DATE -------------- Alterations and/or recommendations:---------- a. -------------------------------- ----------------•------------ --------------------------1---•--------------------- ---------- -.1; ----------•- S FINAL INSPECT BYV_. 2e ff_ %` --- - 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 Reviseci 1-57 F.P.CO.