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APPLICATION FOR SANITATION PERMIT k. Permit No. __ - /{ll (Complete in Duplicate) n . �g a 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 iwifk County Ordinance No. 549. ` �7 f D �Q JOB ADDRESS AND LOCA I N-----''?y'-/ ---- ` ` � •� r - i-'d}. -4 7 DL j Owner's Name-------- �`' _ i�4 ------ - ----------- Address --------- Phone _ t Address--------------•------------------- ----------------------------------- ---------------------------------------------------------------------------•--------------•---•------------•--- 1 Contractor's Name---------------------------------------------------------------------------------------------------------------------------- ---------"----- Phone------- --------------------------- installation will serve: Residence EX Apartment House ❑ Commercial '❑ Trailer Court ❑ Motel E] Other ❑ Number of living units: ___ -- Number of bedrooms -3-- Number of baths __j___ Lot size6-______________________ Water Supply: Public system —Co'mmunity system ❑ Private ❑ Depth to Water Table 20_ €t. Character of soil to a depth of 3 feet: Sand ❑ Gravei ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No L, FHA/VA: Yes ❑ NOA ` i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool perrnitfed if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------- -- --Distance from found tion::�L�_________.Material__ __- ity._: Qd Disposal Field: Distance from nearest well------------------Distance from foundation----------------------Distance to nearest lot line_________________ Number of lines------------------------------------Length of each line----------------------------:.Width of trench----------------------::----------- Type of filter material-------------------------Depth of filter material--------------------__Total length-------------------------------------R ' See age Pit: Distance to nearest —______Distance from fation_ _ Distance�to nearest lot line----- \� Number of pits---- ---------------Lining material - u ize: Dia Depth \ Cesspool: Distance from nearest well__._________'___Distance fro Joundation_________________"".Lining material-----_----------------------------- ❑ Sze: Diameter----- - ----------------- ------Depth-------------------------------;--------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------------------------Distahce from nearest building----------------------------------------- ElDistance to nearest lot line---------------------=---------------------- ---------------------------------------------------------------- Remodeling and/or repairing (describe= ---------------------------------- ----------------------------------------------------------------------------------------------- .k ----------------------------_--------------------------------------___________________.-_ -----------I..----------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- l -1 I hereby certify that 1 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. l F f ' (Signed)----------1--- ��------------------------------------- -------------------- --------`----------------------------------------(Owner and/or Contractor) By------------------------- ------------------- -----------(Title)--•------------------------ ........... -----------•--- - - (Plot plan, showing size of lot, iocation"of system in relation to wells, buildings, etc., can be placed on reverse side). j FOR DEPARTMENT USE ONLY REVIEWED BY-------------------------------------- -- ------------------------------------------------- DATE---------- ------------- -----�1� APPLICATION ACCEPTED BY----------- "_"- --------------- J7/" _________"____ `'-- --- - ----- --- --- --- - ----------- DATE----- :o-1 `" ----------------- BUILDING PERMIT ISSUED------------------ ATE ------------------------------- �f- Alt anon and/or recomm ndations:_- """" � __ �- �___ .�j _ 4 _ij f �. j 'l1__y________-_ -------- -------------------- 41111791-r-1 ---------- --------�rT____--_ __Y _ ___ __ _ -__ ____ -•' i - ___ __ ------------- --------------------------------------- FINAL INSPECTION BY-------- ---------- --•------------------------------------------ e- --- ------------- ----------------------------------------------- SAN -SAN JOAQUIN LOCAL -H DISTRICT = 130 South American Street 300 West Oats Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 FY CQ- y