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1 Permit No. APPLICATION FOR SANITATION PERMIT �r/ ryd (Complefe-in Duplicate) ! / Date Issued � Health District fora permit to construct and install the work herein described. Application is hereby made to the San Joaquin Local This application is made in compliance',with County Ordinance . 549. / ' ----------------------------------------- JOB ADDRESS AND LOC TION___________ __ - --- Phone -- -�^^� --------•-- _ -� --------- wner s ame___._________- r Address -•--- --------------------------- -------- ------ _5 - --------- ----------------------------------- Phone-----------•----------------------- Contractor's Name---------------- --- - �`----- ------ Installation will serve: Residence [Q�Apartment House❑ Commercial ❑- Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __�, umber of bedrooms w--- Number of baths __/--- Lot size --- - -- Water Supply: Public system [a'�Community system ❑ : Private ❑ -Depth'to"Water Table ft Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ y ❑ A ❑ "�"'�``7 Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑n FHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: o septic tank or'cesspool permitted if public sewer is available within 200 feet.) ----Material- -------------------------------------------- Se T Distance from nearest well__Distance from foundation_-__ Capacity______________________ Liquid depth------------------ No. of compartments------- ------------------. Size--------------------------------- ' Distance from nearest well..._-----------Distance from foundation__+------------ Number ---- _- _ ._.Distance to nearest lac line_________________ p' sal FIJI: l Number of lines------------------------- - Length of each line-----------------------=------Width of trench---------------------------------- � __---`Depth of-filter material-----------------------Totallength__----------------------------------------- Type -----f-- Type of filter material------------ --- p Pit: ` Dis#ance to nearest well_. a ----- Distance from foundation__------.---.Distance to nearest lot line_---f©____._ Seepage' ------ l�umber of its.__ -----Lining material__ Size: Diameter--- -- ----------Depth_-_. ------ Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material---____..-_---.------------- als. Depth------------ =-- ----------------Liquid Capacity- ------------------ ------g ❑ Size: Diameter ------------- ---------- -- ----- -__-.____Distance from nearest building-. Privy: Distance from rea�est well---------------L-------- ---- ---.. -� Distance to nearest lot ane----------------------- . Remodeling and/or repairing {descrii�e�:----------------------------------------------- ---------------•----- ------------ ----------------------•--------=:--------------- , ---------------- ----------- --------------- =------ ----------------------------------------------------------------- I hereby certif�r that I have prepared th app lication and that the work will be done in accordance with San Joaquin County State I nd rules nd reguia ions of the San Joaquin Local Health District. ordinances, S 1 Contractorl u_» --- --------------------- - m [Signedl_ ---------- -------- /T �----(Titley _a _ d BY: (Plot plan, showing size of lot, location{of system in relatio�i t wells, buil Ings, a c., can be I on reverse side). F ' FOR D ARTMENT USE ONLY APPLICATION ACCEPTED BY _.--- --------------------------- DATE.,;_..---------------------------------- ---------------- - ------------------------------------- REVIEWED BY - ------------ -----------=------ -------------------------------- BUILDING PERMIT ISSUED---------------------------------------------- ----- - DATE--- ,------ Alterations and/or recommendations-- ----------- - - ----------------------------- --------------•------- --------------- - --------•---•-- -------------------------------- -- -------------------------------------------- ---- ----- ---------------- ------------ - - - -- -------- ------------ Date r ..�� ~ , -------------------------------------- FINAL INSPECTION BY_______________ ._- AN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Tracy, California ; Lodi, California Stockton, California Manteca, California r ES-4-2M Revised 1.57 F.P.CO.