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APPLICATION FOR SANITATION PERMIT Permit 1 (Complete in Duplicate) � Date Issued ___._---__6L_`_'___;l_ 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 ------ s Owner's Name----------- � °'. �---- - Phone-------------------------- Address .e -----------------------------••------------------------•--------------------- ---- ------------------------------------- Contractor's ------------------------------ Contractor's Name-----------=---- L --------------------------- --------------------•----------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J.. Number of bedrooms ANumber of baths I--- Lot size 00 Water Supply: Public system n Community system ❑ Private [Depth to Water Table Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [I Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 6 E]New Construction: Yes No�� FHA/VA: Yes N� If TYPE OF INSTALLATION AND SPECIFICATIONS: ` F] (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) s pticJank: Distance from nearest well--t-41V------Distance from foundation-------------------.Material __________________________________________.____. P Na af,compartments---------- ---------------Size-------------- ---------------Liquid depth--------------------------Capacity----------------------- d � as o Number of lines------------arest II___ p____._.Distance from foundation___a _ Distance to nearest I t line._ - Length of each line_______ /,�_` � �/t/idth of trench...._ ie Distance from ne r� f3 , �;a4 ---- Type of fitter material._ „i'Depth of filter material------/�'"-____Total length------s�-�-_+��_.___ aa,'. .._ YP SeePa Pit: Distance to nearest well____/__ r .__g .��0P___-..Di Lanae to nearest lot line----- - _Distance om f ndation__ __ Number of pits.- .-/------------Lining maferia1 4 Size: Diameter---- ----------Depth---��---------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- Li _._-------.-__-_--.-----_._-__----_. W ❑ Size: Diameter----r---------------------_---_---_-_----_-=DePth------------------------------------------- - ..Liquid Capacity Privy: Distance from nearest weiL___ __ __x___ __________________-_..----.----Distance , from nearest building-----_____.___.__________.__--------_-.-. 1f ❑ Distance to nearest lot line-------------------------------- Remodeling and or repairing describe):----_-______________ � - ------- ---------------•--•--------- ---------------------- ----------------------------------'--------------------------------------------------------------•---------------------=----------------------------••------------------------------------ , -----------------------------------------------------•------- € - - --------•-----------------------•------------------------------------------------------ ------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations ofthe Sa Joaquin Local Health District. (Signed)---------------------------------------- --AF ------ ---- -----------------------------I-------------•------------- er Contractor) BY `� S (rtle) y � ---------- (Plot plan, showing size of lot, location of Sys" in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY ---------------------------------------------------- DATE----------- REVIEWEDBY--------------------------------------------------- ----- ------------------------------------------------------------ DATE-------------- -------------------------------------------- BUILDINGPERMIT ISSUED--------------------------•-------------------------------------------------------------------------- DATE Alterations and/or recommendationsi------------------------ ------------------------------------------------------- ' ------------ ------------------------------------------- -----------------------------------.------------ ------------------------- -�- - - �---�- -- = ----------- ------ - ------------------------ ------------------------------------ ------- ---------- ------- -- ----------- - - �,� FINAL INSPECTION BY:-.---- I / Date--- -- - --`s SAN JOAQUIN 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-9-2M , Revised 1-57 F.P.CO.