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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 2 1 This Permit"Ex Pires 1 Year From Date Issued Date Issued V 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_-------- -------- --------- ------------ -' -=-----------------•-•------------•------------ � --- Owner's Name--------- -- y- nom-�" h� - ---------------------------x------- ------ Phone--------------------------•-------- ------------------- t_ _ ---------- Contractor's Name-------------- -.----------------•-------- -------------------------- --------------. Phone------ Installation will serve: Residence D? Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ._ Number of bedrooms ___%,-_ Number of baths /-____ Lot size ---------l__?�______-_1___�-------------------- Water Supply: Public system Ia Community system ❑ Private ❑ Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ `Clay ❑ Adobe Hardpan ❑ Previous Application Made: 'Yes ❑ No Id Now Construction: Yes No ❑ PAA/UA: Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted_if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------------e _:Distance from foundation_______-_.-___-___.Material ____ ________________________________________T, No. of compartments------------- ---- ' Size--------------------------------Liquid'depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well---s`G-----Distance from foundation_____ d______-Distance to nearest lot line--___-5`..... Number of lines__________/-----------------7-Length of each line-----------,?_ -------------Width of french---------2. ----------._________ Type of filter material___ c. ---------Depth of filter material_______/, _'__.__Total length------------ ________________�_�_t____ Seepage Pit: Distance to nearest well_____.-r�-------Distante from foundation____`©__*___Distance to nearest lot line--.-/_ ....... Number of pits--------/___.-------Lining rriaterial_"_A�.r_1_.Size: Diameter------ ._A!"?`_Depth---%----x___•� Cesspool: Distance from nearest well-----------------Distanto from .foundation--------------------Lining material-------------------------------------- IJ Size: Diameter---------------------------- --------Depth_------------ ---------- f- -------- --------Liquid Capacity--------------------- -----gals, Privy: Distance from nearest well------ _________________________Distance from nearest building_________-.--.-_-.-______________.._--.._. ❑ Distance to nearest lot line---------------------- — � ____._ - ------------------ ,--- - ;------ Remodeling and/or'repairing (describe):----------------- ------------------------------•---•--------------------- -----"==•-------------------------------------------------------- --------------------- ---------------------------------------------------•------------------------------------------------------=------------------------------------------------------------------------------------------ -------`--------------------------------------------------"---- ----------•---••-------------------------•-----•----------•---•-------------------------------------_--------------------------------------------------- p � --------------------------------------------------------------------------------------.----....---•-------------•----------------------------------------------------------------------------------------------------- -----.. 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 of the San Joaquin Local Health District. }- _ .- . - ----------(Signed _ r -----------------.-------- ----- ----------- (Owner and/or Contractor) By------------------------------------------. ---------------- --------------------------(Title)--------------------- ------ ------------ --- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- -- -- -- --------------- ---------------------------------------------- DATE --------------------------- --- ----------------------- REVIEWED BY .. „ .wr BATE �-- ------------ - - - --- - ---- - - ------------------------------------ BUILDING PERMIT ISSUED - -•----------------- DATE ---------------- --------------- Alterations and/or recommendations:----------------------------------------------- ------------------------------------------------------•-----.......---•-------••-•---------------------------- ----- ----•-------------- ------------ ------------------------------- ---------------------------------- -----•------------------•--------------- -----------------------------------•-•-------- - n,, yy1{{ +�(f a --- /�� ---- y v VFINAL INSPECTION BY:.. Date_ --- -- - - --- --- -- ------------ -- ------------- SAN --- -- ---SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r5-9-2M Revised 8-'59 F.P.Co.