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APPLICATION FOR SANITATION PERMIT Permit No. _J��... --0.. I > (Complete in Duplicate) ` l Date Issued 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. S49. (.f/ __� 1 _ 1 --- - JOB ADDRESS AND LOCATI ,N______ ____ __ _________ Owner's Name-----� ---- __ 1 - -----------------------= --------------------------------------- Address _s- .._art _. _: "- 7--- ------- ---- Phoney_ ----- Contractor's Name-==-----•- - ---y�.-�.-��--�>-----�_ �i----------------------------- �-------•---- _. �--- Installation will serve: Residence ,� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -I_ _f- _ Number of bedrooms _ ._ Number of baths __!____ Lot size ____f"0____" •• Water Supply: Public system'N` Community system ❑ Private F1Depth'to Water Table Vp_-ft: Character of soil to a depth 6t 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 0 No� trHA/VA: Yes ❑ No [I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) _ - t' Tank: NoDistance from arnea tst well-----------------Distance from foundation---_----------------Material____.____.-____-______-_______---.------------•- �irilld,: p Size---------------------------=-"-Liquid depth--------------------------Capacity..--------------------- • .t rli pps�0 Distance from nearest well_________________Distance from foundation______._-____-____Distance to nearest lot line_________________ ❑� Number of lines-----------------------------------Length of each line- 7------------------------- Width of trench-------------------------------- ' ------------•-_-__-_---Total length----------------------------------------� Type of filter material-------------------------Depth of filter material Seepage it: Distance to nearest well_l. '`u�______Distanc64�rr m oundation_ _ ___________Distance to nearest lot line_______________ Number of pits----- -------------Lining material---j J- _ -.-.Size: Diameter--- - - :____--..Depth-_--- ----•-----____=• from foundation -------------------Lining material----------------------- Cesspool: nearest well------- iC ❑ Size: Dameter_ Depth - ------------ `\nom -Liquid Capacity----------------------------gals. �} Privy- Distance from nearest well______________________________----________.__-_Distance from nearest building_-___-_-_---_-_______________-._-_______. � ❑ Distance to nearest !ot line______________________ ` -------•----- ------------------------------------------------------ Remodeling and/or repairing (describe);-------- ---------------- ----------•------------ --------•--------------------------------------------•-------- - ------ --------•----... ----•-- _________ _ _ _____________-.__ _______-____________.__________________-._____-_______--.._____"__.__._______________________---._______"_______._______-___________---___.__-_-__________---_-_____-________-- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Counfy ces, State-laws, and rules and �Iationsof the San Joaquin Local Health District.ordinan I S1 ned � _ -- - ----------------------------------------------------------- (Owner and/or Contractor) B �{ r.�° '� `-:---------------- - (Title)----- .. t------------------------------------------- y--------------------------- (Plot plan, showing size of lot, location of system i V elation to wells, buildings, etc., can be placed on reverse side]. , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------- -------------------•---- DATE r ---------- ------- DATE— -- -- - --------------------------- BUILDING ------�-- ----- REVIEWEDBY-------------------------------------------------- -- - -------� ---- - ------ DATE--------------------- ---------------------------------------- Alterations ---------------------------- -- BUILDING PERMIT ISSUED------------------------------- - - - "--• Alterations and/or recommendations------------------ -------------------------------------------------------------------------------- - ------------------------ - K�_O—S— FINAL INSPECTION •BY::_f?__:�......----- -- - _ ------ -Date---�r ---- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California r Lodi. California Manteca, California Tracy, California ES-9-2M Reviseri 1.57 F.P.CO.