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APPLICATION FOR SANITATION PERMIT Permit Noe...1 •yl(� (Complete in Duplicate) /D` 4 This Permit Expires I Year From Date Issued Date Issued ___ C......__ 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 LOCATION---------- -l-----'Y ----------------- -------------- Owner's Name----------------le.�o_.......x y/5j _04- - Phone. Address-----------------_------ r _... ----------- Contractor's Name------------------------- --------- ------ Phonef Installation will serve- Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _2;—'__ Number of baths __/--- Lot size .-__ ---------------- Water Supply: Public systemCommunity system ElPrivate E] Depth to Water Table Voft. Character of soil to a depth oKet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobee Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septicw' k: Distance from nearest well-----------------Distance from foundation--------------------Material__------_._.___-__._________----.---_-_--______- I�Ir J No. of compartments------------------------_Size-------------- •------------ ---Liquid depth-------------------------Capacity----------------------- ispo Yield: Distance from nearest well-----------------Distance from foundation___.___---__-_____-Distance to nearest lot line----------------- D D,j (f Number of lines-----------------------------------Length of each line--------------------------.--.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------`--__Total length_____________:_____-_-__-_- -__r_- S�ep -Pit: Distance to nearest well____.?V�4/c----Distance 4omipundafion___,/p__....___.Distaffe to nearest lo tC Iig�__- _-__.. O I � Number of pits-------I-------------Lining material-_ C -.-Size: Diameter.-�- --------------Depth-vim--- --------_---_-_--- -� Cesspool: Distance from nearest well-----------------Distance from foundation_-----------------Lining material-------_.____._-____._____________-. ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Z. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.____.-.____-----_-___-__-.__.-______- O ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------- --------- ----------------------------------- Remodeling and/or repairing (describe): _______ _ ....... ______________. N a ----- -- -- - ---- ----- � = x------------- -----------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that 1 have prepfrc'gulati7s plication and that the work will be done in accordance with San Joaquin County ordinances, State laws, rules nd of the San Joaquin Local Health District. (Signed)---------------- - 'f x - Owner and/or Contracfor) By:------------------------------------------------------------- (Title)--- - ------------ (Plot plan, showing size of lot, location of syste relation owe s, buildings, can be placed on reverse side. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------- ----- -------------------------------------------------- DATE-- - -------------------------- REVIEWEDBY------------------------------------------------ ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------------------------------------•------------------------•------------•-----.....--•-------•----------------------------------- r - ------------------------------------------------ ---------------------------�------ ------------------------------------------------------------------------------------------------- f i7 = ---- --f /� = - ----------- ------------------- --------------------------------------------------------------------- - ------------------- -----------•----- --------------------------------------------------------------------- FINAL INSPECTION B --------------- - --- -- --- ------------ Date------ IT --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5.9-2M Revised S-'59 EP.Cc.