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APPLICATION FOR SANITATION PERMIT Permit No. �-� (Complete in Duplicate) �!A j, bate Issued __-------•-__ ;! s 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 :r�__---- ! Owner's Name----------------- = i� l ( ------------- --- ---------------- Phone Contractor`s Name-------- _____ __ ___, 1� Q r- -------------------------- Phones Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [ Motel ❑ Other ❑ Number of living units: _ __ Number of bedrooms -------- Number of baths -------- Lot size/(___ c2 ------______,1�7�___�------ Water Supply: Public system Community system ElPrivate E] Depth to Water Table ft. Character of soil to z depth o 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan.[I Previous Application Made: Yes ❑ NoNew Construction- Yes E] No FHA/VA: Yes E] No r TYPE OF INSTALLATION AND SPECIE ,ATIONS: (R'o septic tank or'cesspool permitted if public sewer is available within 200 feet.) eptif Distance from nearest well------- ---------Distance from foundation-------------------Material-----------------------.-___-.-.-_-__- ----. 9A 10No. of com artments________-_ quid de th--------------- Capacity - 5ize ----------------- Li R ... Dis o IrField: Distance from nearest well . ---.____ Distance from foundation---1 '.__-.Distance to nearest lot lin ___- --__-- p i i Number of lines_____________ _ _ Length of each line____-_ Width of,trench_ --------------------- /11 I i,,7 y Type of filter material.__-_ �-____Depth of filter material--i� ---------.-Total length----- �___ See-g it: Distance to nearest well----------------------Distance from fou ndation--------------------Distance to nearest lot-line----------------- B��((� Number of pits----------------------Lining material----------:-:-'---------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation_____________.____.Lining material_____________________...____.______. ❑ Size: Diameter ------------ Depth -- Liquid .Capacity gals. Privy: Distance from nearest well-_______________--__-_----_---------____-____Distance from nearest building.___.._.:_____-___---__-----_------.-. ❑ Distance to nearest lot line------------------------------------- -------- ------- - ------------------------------------ 1 Re"lingnd/or repairing (describe]: ___--- ---- ------- - ------ -- - - ----- ---- --------------------------------------------------------------- -- ------------------ --------- ----- - I I hereby certify thatA have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, rules an regu ions of the-San Joaquin Local Health District. Sined - _____.. _____________________ ___ __(Owner and/or Contractor) U By:---- ------------------------------------------------------------ � -----(TitleP�l �4ed ::: ----- -------------------- (Plot plan, showing size of lot, location of system in relatian +o welis,%in gs, etc., can be verse side). r FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------ ------------ ------------------------------------------------- DATE---------- = REVIEWEDBY---------- --------------------- --------------------------- DATE-------------- ------ --- BUILDINGPERMIT ISSUED--------- •--------------------- ---------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations-------------------------------------- - -------------•--------------------------------------------------------------------------------------------------------- _w -------------------------------•----------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------- FINAL INSPECTI BY: = ----- - ---- Date !-+'1 __'_ -------------------------------------- 6L SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Stree+ 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1 ES-9--2M , Revised 1-57 F.P.CO.