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APPLICATION FOR SANITATION PERMIT Permit No. ...�. ..-?�_ (Complete in Duplicate) fData issued This Permit Expires 1 Year From Date Issued ___ _ ___------ a Application is hefeb� made to the San Joaquin Local Healfh District for a permit +o construct and install the work herein described. Thispapplicatiori is made in compliance with County Or inance o. 549. JOS ADDRESS A CATION----- _ -------_:_ __ -------- ---------- •------------------- --------------•------•---------- ------------------------.... Owner's e- -- c.:_ t' ---- --------- -- Phone---_-------------._....------------- Address- ---------------------------------------.- - - • Contractor's Name------------ --=------- --------------- Phone---------- ------_------•-------- ' �_ +� Installation will serve- Residence Apartment House ❑ �orr r ial-❑ Trailer Court❑ Motel ❑ Other ❑ Number of living units: ---_____-Number of bedrooms Number of baths ___� dot size" __________________ x a— 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 ❑ Nax New Construction: Ye6< No ❑ FHA/VA: Yes ❑ Ncf K TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if p{u�bli?sewer is available within 200 fret )+ well__�)SJ_------Distan e from fou ation__. ()-----------.Ma rial- �. . Septic Tank: Distance from,nearest_ �•� No. of compartments---- -7__�------Size_ aLiquid �epth__.-�T-------------CapacitY----- •- %----- Disp al Field: Distance from nearest well__ --Distance from founda ' n-_ �__ :_-.Distance to nearest lot line -__ ( Number of lines___ Length of each li _ ___ Width of trench__. i -- -- --------- r5 till I' -f i Type of filter ma+eri _:' Depth of filter ma na1___._� -----------Total lengfih___: __- - / Q , Seepage Pit: Distance to nearest well'/'P_6� __Distance from' ro. foundation to nearest lot line-_-_-_, ___ Number of pits-----_--/__-______-Lining materials/`�1t�fa5--_Size: Diameter_.____ ��_//------Depth_------€-Z_5______________ Cesspool: Distance from nearest well---------_----___Distance from foundation---------------------Lining material__.__.__________-_._____.________. W I ❑ -- _ Size:-Diame#er + ------r-- --------_Depth------.---------------------------- -----------------Liquid Capacity----------------------------gals. GA Distance from nearest`buildin '° Privy: Distance from nearest well----- -_--------- ----------------------- g -" ❑ �' Distance to nearest lot line.----- - ----------------------------------- - -----=-------------- - -----------------------------------------_--------------------------- F - ----------------------- .F • Remodeling and/or repairing (describe):_...-----_--------------------- ------------------------------- ------------ ir. i I hereby certify that l 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. I r____f______.._.____.Owner and/or Y y S� ned '�+ 7 { / Contractor) 3 by:-------------------------------------------------- ---`---------------------------------- ---------------------------------------------(Title)------------------------- -------------- -------- s (Plot plan, showing size of lot, location of.sys+em.in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY------------- - --- ---- - --- -- - - ----------------- ------------------------------ DATE--- } 4 t— (9ti�------------------- REVIEWED BY------------------------------------ -- --- ------ --------------- -- -- ------------------------------------------- DATE---- ----------------------------------•------------------ BUILDINGPERMIT ISSUED-------------------------------------------------------------- -------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------------------- ----------------•------------------------ -------------•--------------------------••---------------------------- -----------------•----------- ----------------------•--------•-------- ----------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------•------------------ - -----------------•----•------- --------------•-----------------------•--------------------------------------------- ---•-•------------------- ----------------------------------------------•------ -•------------------------------------------------------------------------------------------------------••-------------- - - ----------------- ------- ---------------------------------------------- - ------------------------------- ------------------------------------------- ~ C d ------------------- FINAL INSPECTION BY:_.. __ Date....�I -----------------=------- ' n SAN JOAQUIN LOCAL HEALTH DISTRICT 1 0, ; r ,'t r 130 South American Street 300 West Oak Street' 1` " 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California �` ES-9-2M Revised 6-'59 F.P.Co.