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APPLICATION FOR SANITATION PERMIT Permit No, .......... {Complete in Duplicate} Date Issued -_ _G/. plication is hereby made to the San-Joaquin Local Health District for a permit to construct and install the work herein described. }1)1 This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION -----/_----------- ---0F2_Z_F, ------------------------- - ------------- Owner s -------- Owner's Name__'------- -�--��-��:, - ---n--------- ----- ------------•--------r-----•----•--------_- T / y� _ ----- Contractor's Name_ _ _ - 4--•------•---------------------------- ------------------------------ ----. r -------------- Phone------••---•-•--------------------- Installation will serve: Residen a [�partment House L] Commercial ❑ Tfiler I Court 'E] ❑ Motel //Other ❑ Number of living units: ___-_ Nu ber of bedrooms F = Number of baths Lot size , Water Supply: Public system Commun'ify system ❑' Private [] Depth to Water Table _______ ft: I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe rdpan [I Previous Application Made: Yes EKNo ❑ New Construction: Yes .2-'_N�o ❑ PHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: 4� - ' {No septic tank or'cesspool permitted if p blit sewer is available within 200'fe }.)' ` ,..... _ �} . . -it- Septic T nk: Distance from nearest well_--__ -Distance from foundation__.:__ ' f No. of compartments_-_ --'___-,__,_A.__Size____ ____ Liquid Be th1 O a__- �y6 �om .` -.- / --------- ------CapacitY-}--�------ from Disposal Field: Dumber of I nesearest we11-F L} taofreach I ne atio -41Jg -.WidthCofttre Wiest lot line . !� Length - Type of filter material_ ,-_!-'Depth of filter material_-_.___/__M C( Total: length - - Seepage Pit: Distance to nearest well_'__-________________Distance from founda#ion__.-�.. .. ._.Distance to nearest lot line_- _-_______._ E ❑ Number of pits---------------------Lining material-------------------------Size: Diameter------------------------Dept h_'-------------------------------- Cesspool; ------------ -_-------Cesspool: Distance from nearest well------ _Distance from:foundation____________ __ __Lining material-- --------------------------------- ❑ Size: Diameter Depth-_r- ----- --- Liquid Capacity = gals. Privy: m n eatesf iinle------------- ----------------- ---------- Distance from nearest building------------------------------------------ ❑ Distance to Remodeling and/or repairing (describe)--------------------------- -------- -------------------------•-------------------- --------------•--------------•----------------------------------------•---------------------•----•-------------------•------- - 4---------------------------------------------------------•--- ---------------------------------------------------------------------•---------------------•------------• -----------------•--------------•--------------- I hereby certify that I have prepared this application and that the workfwill :be'done,in accordance with San Joaquin County r. ordinances, State laws, and rules and regulations of the San Joaquin Local_Health District. ed) -1'j--- f t - -- ---------I------------------4------- --------------------------------------------------------------- ----- - ----------- ----------{Owner and/or Contractor) By:---------------------------------....... '=------ --------::-----------•----------------------------------------------------(Title)-------------•-------------------------------------------------- (Plot plan, showing size of lot, loca+ion'of-system in relation to wells, buildings, etc., can be placed on reverse side). , t • FOR DEPARTMENT USE ONLY s } i APPLICATION ACCEPTED BY `; --- ------ ---------- ---------------------------------:-------------------- DATE------------------f- ----------------------- -- --------------------------------- BUILDING PERMIT ISSUED------------ '4 -- ------- .--- ------------------------------------------- DA EE_ y REVIEWED BY_ _ Alterations and/or recommendations:_' - ------------------- -----=--------------------- ---------------------------------- = -------------------------•---- -----------•--•--------------------------------------------------------------- ----------------------------------------------------------- ---------------------------------••------ y ---------------------------_---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_----------------- --------------------- -..... -----------------------_----------------___-----------------------------_____-------------_------ ____________________ - FINAL INSPECTION BY:_ __- :- -• -- -• -- - Date--- ._. -------- ---------------------- SAN ------- -- -� 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.