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I APPLICATION FOR SANITATION PERMIT Permit No. /....___. I (Complete in Duplicate) Date Issued ________f___ __�� Applical,ion 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 Ordinan No. S49. JOB 'ADDRESS ANDOCATION_ ---�_------- - -- ,��• , - Owner's Name_ i '�' .1--•- - --- ----- ------------------------------------------ Phone_ - �-`�-- '2 Address_._. ... ----- A ------------------------•-------------_--- ----------- --------------------------------- -------: _ Contractor's Name --- Phone` I Installation will serve: Residence :Apartment House E] Commercial ❑ Trailer Court ElMotel IDOther El Number of living units: __�__ Number of bedroomsa- � Number o€ baths -_/__ Lot size _- �_ --------------------._-______ Water Supply: Public" stem� 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 ❑ No]� New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: `-(No septic tank:or cesspool permitted if public sewer is available within 200 feet.) 4i1sposal. tic Tynk: *Distance from nearest well_____________ _ Distance from foundation--------.-.- -_--Material___._----__---- i-.-_--______-_._________- - , No'. of compartments ' : P---------------------------- ----Liquid depth Capacity W 501 ,Distance from nearest well f`�_�___Distance from foundation._____-------------Distance to nearest lot line..__.___________ /: Number of lines--- ------------------------- ---Length of each fine------------------------------Width of french.------------------.---------_----- Type-of-filter-material------------------------Depth of filter material_------------ --------Total length------------------------------------------ Seepage Pit: ,.;Distance to nearest well ____Distance,From,fo ndation �, ___------Dar�ce to nearest lot line___y ___-__ Nu fiber of pits ..... Lining material ___ yt,.__.Size: Diameter______ _____ ___ ____Depth___ _-____.__. ------ 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------- = --------- --------- = ------ ------------_-------- ------------------------ n Remodeling a /a repairing (describe}: Y r - =-tel -v=L: ^- - a �-_ Ir ---------•---------=--------------------- --=---•--------•------------ ------ ----=--------------------------------- h reby certify that I have prepared this applica ion and th4f"'the work will be hone in accordance with San Joaquin County ord.nances, Sta laws, d Ies and j'regulations of the San Joaquin Local Health District. I(Signed)_______ __-�� _..- .. �____- _ __ __(Owner and/or Contractor) I - - ---- - -------- - -------- -------- - ------ --- -- - d By:------------- - --'-�--• ----------------------------•------------------------------•--------------------------------------Title------ - -- ---- - ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pla ed o reverse side). ` 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ---------- r1 r` ---'DATE------------------- -----------------;-,�:------ BY - - ----- DATE ._-------------- REVIEWED I3UILDWG PERMIT ISSUED - ...... --•-------------------------------- ------ DATE.--•------------•---_ -`------V------•----------•---•-,--- Alterationsand/or recommendations,____.__.-----------------------------------------........--------------------------------------------------------------------------••-----•---------------.-== ------------------- ---------•-------------------------------- ----------------------------------------------------------------------------•------------•---.._..--.._..-----------------------------------------------...- --------- , '------------- -----A-----------------' 1--- •------- ------------ `.- 1a. - . '' ------------------------------------------ ----- ---------- ------- ------- FINAL INSPECTION BY:---- --------------------------------- Date---- .-2 /• / SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy,yCalifornia ES-9-2M Revised W-2140