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APPLICATION FOR SANITATION PERMIT Perr6it No. -Zjq-jc? ----------- (Complete in Duplicate) Date Issued V_(__'61_4�-Y 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------ ------ Z ---- ? -- ----------- `-------- Owner's Name ------------ ----------------------------- ----------------------------------------- Phone Address---------------------- -------- Contractor's Name-, Phone. Installation will serve: Residence g?'Aparfment House El Commercial F1 Trailer Court El Motel [I Other 0 Number of living units: __-/. Number of bedrooms ___~?Number of baths --- /-- Lot size * - -------------- Water Supply: Public system [Community system El Pr4ivate E] Depth to Wafer Table 4_40 ft. Character of soil to a depth of 3 feet: Sand E] Gravel 0 Sandy Loam 0 Clay Loam E] Clay [3 Adobe @3"Hardpan ❑ Previous Application Made: Yes E] No 21New Construction: Yes 0 No El FHA/VA: Yes El No E� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well------ ---------- Distance from foundation ------------------- Material ------------------------------------- ----------- No. of compartments-. ------------------------ Size -------------------------------- Liquid depth-------------------------Capacity--•-------------------- D lepth-------------------------Capacity----------------------- osqj_ 10: Distance fr&ii'nearest vi6li - — ----------- Distance from foundation -------------------- Distance to nearest lot line____________._... Number of lines--------- ------------------------ Length of each line -----_-----------------------.Width of trench-----------.-----------_-----__---- Type of filter materna.__ -------- Det p -h -Total length--------------------------------------- --- fo e X ion_-�-47 ------ Distance to nearest lot line ------ --------- •Seepage Pit: Distance to ce ron� fo da t( n Number of pits' mate 'al ------ ____--Size" Depf h" - -- ---------------------- Cesspool: Distance from,nearest well --------- Distance from foundation- _1 ------ .____.Lining material__________..______________________- F1 Size: Diarrieferl ------------------------- Depth ------------------ I ------------ --------- ----- Liquid Capacity-. -------------------------- gals. Privy: Distance from nearestswell_____________________________________________--- Distance from nearest building -__---._______.____________________._____.1 ❑ Distance 0cling------------------------------------------ Distance to nearest lot line_ ------------------------------------------ ----------------------------------------------------------------------------------------------- n�Remodeling and/or repairing (desc. ------ ---------- I ----------------------------------- ---------------------------------------------------- --------- ------------------ ---------------------------------------------------------------------------------------------- --------- Z ------------------------------------------------- 44 ------------------------------------------------------------- ------------------------- ---------------------------------------------------------------- ------------------------------------------------------------ I ---------- 2 -- ----- ----------- I ---------- W -------------------------------------------------------------------------------------------------------------- I hereby certify that I have preparei'this application and.f . hat 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. (Signed) --- C.Z�b A__101 ------ ---- ----- ------------------------------------------ Contractor) By:� ...................... -------- �_ a an be placed an reverse side). - ---- - --------------- - - (Title) ---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relatio jow�ells, buildings, rfc., c' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- ---------- ----- ------------------------ ---------------------------------------- DATE ------------------- �--t --- I ----- ---------------- REVIEWEDBY------- --------------------------------- ---- --- ----------------------------------------------------------------------- DATE---------- - -- ------------------------------------- BUILDINGPERMIT ISSUED-------------------- - - ----- ---------------------------- ---------------------------------- DATE._-- --------------------------------------------- Alftions and/or rec��!nenclafions: -------- -- ------------ ----------------- ------------------------ --------------------------------------------------------- ;75 ------------------------------- ....... to- _T�=_qA4_1 ------------ 3 _Z:: ------ C ------------- -- ---------------------------------------------------------------------------------------- ------------------------------ I ------------------------ ------------------- ------------- ------------------------ I -------------------------------------------- ------------ ------------------ ----------------- --------------------------------------- --------------------------------- ------ - ------------------------------------- --------------------------------- -------------------------- ------------- ------ ------ -------- FINAL INSPECTION BY:--------ee-4 ---------------------------- Date ---------- rr-:� ns -1 ---- ---------------------------------- SANJOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -11-2M Revised 1.57 F.P,CO.