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APPLICATION FOR SANITATION PERMIT r r , Permit No. .-�_��.. (Complete in Duplicate) �_ �`}� Date Issued .__.. .___.. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------- ------- ------------------------------------------------------------------------------------- Owner's Name----------------------------------------- ----------------------------------- - ------ Phone.---------------------------------- Address-•--------•------------------------------------------- R ......... ----•--------------•---------•-----------------------------------------------�-------------------- Contractor's Name --- -- - Installation will serve: Residence 0_ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___4 Number of bedrooms ___1--'Number of baths ._,f___ Lot size _____I-_____________________________-_------_-_-__-__--.__._ Water Supply: Public system'R' Co Fnunify'system ❑ Private ❑ Depth to Wates Table V10 ft. Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ,Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑e� � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S6c Ta k: t Distance from nearest well_________________Distance from foundation______-_____-_-__.Material______._.______.____._.______________.__-.--_._. ® � No. of compartments----- ------------------- Size--------------------------------Liquid depth-------------- -----------Capacity------------------- 5ra Field: i Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines-`-------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material________________---------Depth of filter material-----------------------Total length------------------------------------------ Seepage __.____..____-_________________________- • p ge Pit: Distance to nearest well._ f '4 _____Distance fr 'rrh fo ndation__ __*�~.Distance to nearest lot line---f_�_� W Se m Number of pits________ ___________Lining materia �k� n p � ' ��. _--�^w1'�..Size: Diameter--�-�-- --------De th---�--�----------------- Oa 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----------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing describe):------- ------------------------------ --------------------------------------- ----------------------------------------------------•------------------------ ---•-------••----•-------•--•----------I------ ---------------•----•--------------•------- -----------------------=-----------•-•-------------------------------------------------•------------------------------- ----------- ---•�_ _______________________________ - ------------------------------ • ----------- ` f I herebycertify that �y�pre are9 fhis a lica#i�ori and that the work will y �" p pp be done in accordance with San Joaquin County F ordinances, State laws, an rules and re ul tions of the an Joaquin-Local Health District. i (Signed): -----------6Art------------ ----- ------- By..__ = =,r(.Qwner and/or ntractor) [Title C) l _ f By----------------------------------------------------------- I----- F----8_f)[A-4, - )----- (Plot plan, showing size of lot, loco ion n b_f"%y tem,in relation to wells, buildings, efc. e placed on reverse side]. f � s .� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- ------------------------------------------ DATE_ ------ !a REVIEWED BY-----------------•----------------------------------------------------------------- -------- -- -------- ---- --------- DATE--------------------------------------- - - - -------------------- BUILDINGPERMIT ISSUED---------_----- ---------------------------------------------------------------- ------------------ DATE---------------------•--------- ----- •--------------------- Alterations and/or recommendations:-------------- --------- ------ - --------------------------------------•------------------------------------------------------------.---------- -------------------------- ----- ---------------------------------------- ---------------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------------------ --------------------------- ------ --------------------•---------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- ---------------------------------------------- -----------------------------------------------------------•-•- -------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY: - ----- Date-- ------------ ----------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-2M 0-52 Revised W-2100