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APPLICATION FOR SANITATION PERMIT Permit No. �. (Complete in Duplicate) i z�3 SIS 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 ATION........`-7 --�----- '-------- - -- --------------------------------------------------.- Owner's Name. -------- Phone %_" d - Address--------------------------Y. -- Contractor's Name - - ---------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer out,❑ �h0% ❑ Other ❑ Number of living units: I----- Number of bedrooms __.r Number of baths _._`Lot size 1_: __„ G --�____________ _____ Water Supply: Public system [Community system ❑ Private ❑ Depth'to Wafer Table A& ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 9 Clay Loam ❑ Clay ❑ ` Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [T" New. Construction: Yes ❑ No R?O*'FHA/VA: Yes 9?' No TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_v � __Distan,c�^e� frpm foundation___��_________:Materja� _ __ --- No. of compartments_____. _ s _Size_a,/___.b V Q______..Liquid depth______ Capacity____ ._ �______ ---- --- / Disposal Field: Distance from nearest well__ __Distance frot ,fpundation__f _______Distance to nearest I t line----- [L]� Number of lines------------------ of each line________ Width of t enc Number Type of filter material--/4L. Depth of filter material Total lengh � Seepage Pit: Distance to nearest well_ ____Distance foom' f�ndatiorJ--- ,,, ......D.J'stance to nearest lot lin�______ ______ \(� ®/ Number of pits-----/--------------Liming material.. p \� _ ••-- -____--Sizer Diameter _----___D� th____f=��----------------- Cesspool: Distance from nearest well-----------------Distance from foundation'-------------------- material-------------------------------------- 0 ❑ Size: Diameter. Depth }--------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_____________________________________________Distance from nearest building'----------------------------------.___._. ❑ Distance to nearest lot line------- ------ A------------------------ --------- ----------------------------------------- Remodeling and repairing (describe) -------0?� A --------------- -------------------------------------------------------------------=----------------------------------------- -------------- ------------------------------------------------------------------ - ---------------------------------------------------------------------------------------------------------------- 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, and rules and gulations of the San Joaquin Local Health District. (Signed)----- --------------------- ---------------( os.Contractor) gY: ---- --- ---------------------- ------------- By: plan, showing size of lot, location stD'inion to wells, buildings, etc., can be placed:on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYV DATE 7--------------------- - REVIEWED BY----------- - � -- ---- - -- --------------�-•----. _-- - ------------------------------------------------------- DATE--------------------------='�---�--------------------------- BUILDING PERMIT ISSUED--------------------------- ----------------------------------------- DATE--------- Alterations and/or recommendations:_-__ -----------------------------------------------------------------------.................-------- --------------------------------------------------- . r --- - -- --------------------- --- ---------- - --- - ------ - - -- - - ---- - ------------------------ ------ ------------------ ---------------------------- ------------_------ - ----------------------- 1 - _ - —a__` ------------ =- ------------------------------------------------------------------- ----------------- ---------------------------------------------------- -------------------- �� 5 FINAL INSPECTION BY:----- - ---- -Z- -- ------Y-----_- Date.... f-----.------- ------------------------------- SAIJOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Streit 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO.