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IZ ' APPLICATION FOR SANITATION PERMIT Permit No. .1 6 (Complete in Duplicate) / /?T1 bate Issued _""_1- 8- 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. 49. JOB ADDRESS AND L CATION"�." ,�' q ��- . �r�) � p Phon` -------------------------- -- ----------------------------------------- Owner's{ Name-""-"_""___Qf�] _ Address"_"_._""__"_ � Y". r--------------------------------------••--------------------•-------------------------- -----•-----------------------•-----•- Contractor's Name-------------- .. ---------------------------------------------------------•--------------------- Phone Installation will serve: Residence E] Apartment House Commercial ❑ Trailer Court ❑ Metal ❑ Other ❑ Number of living units: _ " Number of bedrooms _/�- Number of baths _1 Lot size a!� . ��_ Water Supply:I Public system yCommunity system ❑ Private ❑ Depth to Water Table " ' O ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [❑ Adobe &--'Hardpan ❑ Previous Application Made: Yes ❑� No I� New Construction: Yes �No ❑ FHA/VA: Yes El No [ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if.yp�ubblic�s�ewer,is available within 200 feet.) Septic Tank: Distance from nearest wel -Distance from foundation__- - No. of compartments---------- ---------------- _• __Liquid depth_..... -...-__- _-_ pacy_ .—Disposal Field: Distance from nearest weTh ?LG-_'Distance from foundation,--- / I _ ."""-_.Distance to nearest lot line"�_" P_" Number of lines-------- ----r--------__ Length of each line------e,�"Q%----------.Width of trench------ ".- ------ Type of filter material- " Depth of filter material" f "i� — .1 Total length 1 .6• F Seepage Pit: Distance to nearest well_ `Distance from fou a#ion_-_IAO?." _ oo�� ---.Distance to nearest lot line----- �"_�__ p� Number of pits-----_Z- -----------Lining material/As-4—Size: Diameter_-" `. s � ��-- ----- --Depth------�-`-3`--- -------- - Cesspool: Distance from nearest well-----------------Distance from foundation-_ Lining material------------------------------------- ---------------- El Sze: Diameter ---------- Depth-----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well------------- - --_.__"""__"--__...""___".__-_Distance from nearest buildin _ __ Re ❑ Distance to nearest lot line Remodeling odeling and/or repairing (describe]:--:_..__._--_--( _ -- -------- - I s --•----------------•---------- ---------------------------- ----------------------------------------------------- ---------------------------•--------•------------------------------ ---------------------------------------------•--------------------------------- I hereby cert_ify.:thaf I..have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfafe`laws, and rules a dfregulations f the San Joaquin Local Health District. I (Signed) By: -----------------------------------------------------------(O t" Contractor) r - --------------------------------- - Title---- ---- ------ ---------- (Plat plan, showing size of lot location o ysfem in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___-_____ ----------------------------- DATE-------- REVIEWED BY = ------- -------'--------- ---------------- f " " Jl ------------- --------- - --------- - DATE --------- BUILDING PERMIT ISSUED--------------------- Alterations and/or recommendations: -- � ----------- -------------------------------------- DATE---------- -------------------------------------------------- "_-___ . -- ----------- -------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------- ----- FINAL INSPECTION BY:------- ."_ -_ ------- Date-----j-r------ 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.