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APPLICATION FOR Permit No __ _ _ SANITATION PERMIT f� ...�... x ��J � {Complete in Duplicate} , - r 1 C1� 1 Date Issued __..__l_____ _ j This Permit Expires I Year From 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. JOB ADDRESS AND LO TION - Owner's Na e--- 4". ------ .C. l-d---------------------------- ---------------------------------------- Phone-��' " Address__ -------- {.------------- Contractor's �------- -lef1f,----------------•----------------------------------------------- Phone-�. ----4;�4 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/------ Number of bedrooms Number of baths - -- Lot sized X .Q Water Supply: Public system Community system [:] Private [-] Depth to Water Table _loft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobN�j Hardpan ❑ Previous Application Made: Yes ❑ Norst-_New Construction: Yes ❑ No_'Y,FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted if public s wer is available within 200 feet �r _ 'fes!► Septi Tank: Distance from nearest well_!]_-_____._.__Distancef ro4noun,1afiorr-*#_________________Ma _ _.No. of compartments _ ______-_.Si _____Liquid depth_p _...___--.__Capacity_XW-w "` Disposal Field: Distance from -neares we I.A.a�J._Distance froat _____Distance to nearest lot line_____---------__ NA Number of lines______ _ _ ___________Length of each line----,9-.C-�__ ---- Width of trench___._.!____`� � a ----------------- Type of filter material_ Depth of filter material ----------------- Type length_--_-___ C�..!----------------- See a e Pit: Distance to nearest well �� _____.-__Distance f om foundation___-��_ ___.Dist*a�� to nearest lot line___ __Size: Diameter____ __. Number of pits-----/------------- Lining material--------�."---- e1------ --Depth_...-�--�----------.-.._. ' Cesspool: Distance from nearest well------------------Distance from foundation......--------------Lining material------:_________________----____-___-- ❑ Size: Diameter- _r--------------------------------Depth----------------------------------------------------Liquid Capacity---.-------------------------gals, Privy: Distance from nearest well----------_---------------------------------_._Distance from nearest building ❑ Distance to nearest'lot line-------------------------------------------------------------------- Remodeling and/or`repairing (describe):___ ____________ ------------------------_ _ -- ------ ----------------------------------------------------------------------------•----------------------------------------- -------------------------------------------------------- -----------------------------------------•---------••-•---------------------•--------------------------------------•------ =' j I hereby certify that I have prepared this applicationd that the work will be done in accordance with San Joaquin County i ordinanceg�c5t }e lawfrules and regulations of the an oaquin Local Health District. (Signed} ----- nn,, �I --------------------------------------- - ----- - =-------------------- --------------(Owner and/or Contractor) By. VEF-111C TANK � y ----------- - ----- - -------- -- (Plot pian, snowing�size of�$t, �oca+o of system in elati to wells, buildin s, etc., can be placed on reverse side). 'F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---___-• --------------------------- DATE..... k ------- -• -- - ---------------------------- -- ---- REVIEWEDBY----------------------------------------- ---- -------------------------------------------------- :--------------------- DATE------------ -------••-•------------------------------------ BUILDING PERMIT ISSUED ----------------- --------------------------------------------------------------------- DATE Alteratio s and/or recommendations;---=Y----------- -- ---------------------------------------------------------------------•----------•-------------------•-------•------- ---- ------------ A _---------- ----- - FINAL INSPECTION BY----- -- -- -- --- ------- -------------- --- ------------ Date lJ � '°� L SAN JOAQ IN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street i Stockton, California Lodi, California Manteca, California Tracy, California F ES-9-2M Revised 8-'59 F.P.Ca. hr