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APPLICATION FOR SANITATION PERMIT Permit No: _/1,0f (Complete/in .1 3f(Complete/in Duplicate) /— Date Issued ---- /..a- _- 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 Ordinance49. JOB ADDRESS AND LOC TIO - -•------ -- `--------- ------------------------------------------------------------------------------------------- OwnersName------ ------------- - --- -- -------• ------ -------- ------------ ----- Phone------------------------------ Address---------------"------------ I G Contractor's Name------ ' / ------------ Phone £n I Installation will serve: Residence 1�1_ artment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ _. Number of living units: Number of bedrooms -,.2— Number of baths --/_ Lot size _._��_��a�_______________________ Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table 'Ks--- ft. Character of soil to a depth of 3 feet: Sand.❑ Gravel ❑ Sandy Loam [—❑ Clay Loam p Clay ❑ AdobeQr'�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.) Se ank: Distance from nearest well-----------------Distance from foundation--------------------Material __-___-__-_---..--.---_.__-_-------__----____-. 7 No. of compartments-------------------------Size---------------•------------ ---Liquid depth------------- ------------Capacity------------------ D' o I 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----------------------- length------------------------------------------ Seepage --___-_--------------------------------- p g ,1Z1'►'aP _Dista E ro f undation- i See a e Pit: Distance to nearest well_ _- _.____ - -!�_J__..--_-..�tapce�`to nearest lot line-.�Q_-_---- 0� Number of pits----/--------- ---Lining materia.----Size: Diameter--------- --------Depth--- --r/----- /1 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 kne---------------------------------------------- ------------------------------------------------------------------------------------------------ Remodeling and/or repairing I(describe)---------------------------------------- -------------------------------------••--•----------------•-------------------------------------------------------- -------------------- ---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- ------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------•-------------------------------------- ! hereby c tha+ I have prepared this application and that the work will be done in accordance with San Joaquin County ° ordinances, Stylel�a , and rul s angulations of the San Joaquin Laca! Health District. {Signed) ---- - - ---------------- ------------------------------- -- ---- (Owner and/or Contractor) By=---------------------•-----------`-------------•-- -- - ------ ----------------------------..-.(Title)-------- ------------------------- (Plot ---------------- l (Plot plan, showing size of lot, location o system in rela+io owe Is, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY { APPLICATION ACCEPTED BY--------------------- - --- ------------- ----------------------------------------------------- DATE------------- �} REVIEWED BY-------------------------------------------- -- DATI= = -1 k� 5 BUILDINGPERMIT ISSUED------------------------- -- ---------------------------------------------------------------------- DATE Alterations and/or recommen ations:--------- -----------------------------------------------------------------------------------------------------•----------••------------•----------- ---------------------------------------------- -------------- -------------------------- --------------- 1 -- ---Z-- / --------- ----- -- --------- - � --- -- ---------------------- Z- ------�---- ---- ------= ^ -- --- <Q - ------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- f f - (Ja FINAL INSPECTION BY------------�--11.- - --- ------------------------------- Date---------i--------------- - --- --•--- - ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revisea 1.57 F-P.CO-