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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) r (p S Date Issued r Application is hereby made to the San Joaquin Local Health istrict for a permit to construct and install the work herein described. This application is made in compliance with County Ordina e No. 549• JOB ADDRESS AND OC TION--00r-__ •-_. - --- - - - f pQ Owner's Name------- --- ---at�f"'�---• -�•- --------------•--------------------- - ------------- --- -- ------------- Phone------------------------------------ I Address ., -------•-------------------------------------------•-••------------------------------------=---- Contractor's Name f ---------------------------------------------------------------------------------------- Phone----•-- Installation will serve: Residence ❑ Apartment House [❑ Commercial ❑ -------- Trailer Court ❑ Motel ❑ Ot er c Number of living units: Number of bedrooms __"� Number of baths e�x Lot size __/_ ----`------------------------------ 1 Water Supply: Public system ❑ Community syst 'll Private 2?"tepth to Water Table Aklft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 03- Rardpan ❑ Previous Application Made: Yes ❑ No I- New Q onstruction: Yes 2?"�No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No''septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well__I..;��_-_-_Distance from foundation---fp----------Mat ria;--__C__6_ -. No. of compartments--------------- -- -----Size-_- ___Liquid depth------Y-k Capacity...�QQ- -- Disposal Field: Distance from nearest weilf._rr1-..._....Distance from foundatlon____A(1:..........Distance to nearest lot 1p— Number of lines- --___-I---I_ _ Length of each line-----_��0__**___-_-_-Width of trench.---!�i4f0{-_-------_- -- ----- ------ Type of filter material_/j7_ _ _ ---Depth of filter material-----/ �a-------Total length------ F____________________ Seepage Pit: Distance to nearest welJ_1---------------Distance from foundation___----___- -_---.Distance to nearest lot line---_------------ \ ❑ Number of pits--------------f-AF Lining material---------------_-------Size: Diameter------------------- ---.Depth--------------------------------- G 1 Cesspool: Distance from nearestell----------_------Distance from foundation-------------- ----.Lining material--_____-_---_-----_-___-___--__----- ❑ Size: Diameter-------------� -------------------Depth----------------------------- ----------------------Liquid Capacity- - -----------------------gals. Privy: Distance from' nearest.well-------------------------------------------------Distance from nearest building------------------------------------------ El i Distance to nearest lot bine----------------------------------------------------------------- Remodeling and/or repairing. {describe7i-- -------------------s-- ------------------------------------=--= Y ---- i --------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ---------------- ------------------------------- ------------------------- ------------ -------------------------=-------------------------- -------------------------------------------------------------------------- -------------------------------------------------- ------------------------------•-------------------------=--------------------------------------------------------------------------------------------------------------------------------- --- ------------------------ . 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, an rules and egulations of the San Joaquin Local Health District. l (Signed)------------------ ------------- -- ------ - ------------------ ----- -------------------.----------------------------------------------------------------- ------- (' r Contractor) By:--------------- ---------LlocaLtlion?sysfern ----------------------------------------(Title)------�� ---N--- ---- --------------- (Plot plan, showing size of lot, in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED SY----------------- -- ------ ------------------------------------------------------------ DATE----------- -------------A------------------------- REVIEWED BY----------------------------------------- - --- - DAE--------I- r �BUILDING PERMIT ISSUED------------------ --- ---- ------------------------------�--------------------------------------• DATE-- ------ - - ----- Alterations and/or recommendations:- --------------------------------•---•----------------------•--•-------------------------•-- -•-----•-----•------------------------- -- •------------------------------------- --------------------------------------- ' ----------------- -----------------•-------------------------------------------------------------•---------------------------------------------------------------------•----------------------•------------------------ I ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - -------------------------------------------- ----•--------------------------------------------------------- -----------•-•-•------------------ ------------------------------------------------ yl FINAL INSPECTION BY-------- ---------------- °-tif--------------------- Date 1 ----------------------------------------------------- SAN JOAQUIWLQCAb HEAi:TH DISTRICT 130 South American Street 300 West Oak Streat q 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California. \Manteca, California Tracy, California ES-9-2M Revisea 7.57 F.P.CO.