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Permit No. A .4-��•- APPLICATION FOR SANITATION PERMIT Per_ (Complete in Duplicate) Date Issued i Applicafion is hereby made to the.San Joaquin Local Health District for a permit to construct andinstall the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------9?-T--+---- _frft ------ _". ---4`------- Phone------ ---------------•------------ o--- --------------------------- ---- ------------ ---;- ------- - ------------------ - - �, Owners Name-------- + ------------- Address_---------- --------------------------------- = " ------------------------------------- Address _ `� Contractor's Name '--- - - Phone-----------•---------------------- Motel ❑ Other --------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ❑ --- Number of bedrooms Number of living units: _� ___:Number of baths ______ Lot size __ ----------------- Water Supply: Public system ❑ Community system e—Private ❑ Depth to Wafer.Tablet- Character of soil to a depth of 3 feet: Sand ❑ . Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made: Yes ❑ No [A' New Conkucfion: Yes Jo ❑ FHA/VA: Yes A]O'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:, (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ee Septic Tank: Distance from nearest welf_7 Disfance from fo ndafion___ ______-.Maf' rials G�_ ------ i Alid � ----- Capacity..I"- �' No. of compartments_____ - --- _ _Size. . _ _- -- --.Liquid depth_ _ -- _.: __Distance from.foundation____-AA------.Distance to nearest lgt liner--�-------• Disposal Field: Distance from nearest wei1�� n I' Number of {fines-____ - - --- ----- ------Length of each line__------;� -Width of trench.-___ __ --------------- ----- f Type of filter material__ _- _____-----Depth of filter material----;1 -- ------Total length------ ---------------- d � _. r z � ,� Seepage Pit: Distance to nearest well_: --2Distance f m f ndation__,_. __ _.__ bistance to nearest iof,line_ Lining material-- Diameter__ ---------.Depth------ --- ------------------- P �' Number of pits__'-_ - f. Cesspool: Distance from nearest well_________________Distance from foundation_____._._________ _lining material____--__-_________--------------els. Size: Diameter------ -----------------------------Depth----------------------------------------------------Liquid Capacity----------------------- g ❑ Privy: •� Distance from nearest well-------------------------------- -�--------- --Distance from nearest building-------------------------------- -- -----� . Distance to nearest lot Ione--------------------------- ----- •-•--------------------�--- -- - ---------- ------------ --------- -- Remodeling and/or repairing (describe}:- --- ------------------------------------- -------------------------------------------------------------------------------- ----------------------------------------------------4- -------------------------------- ------------------------------------------- ---------------------------------------------------:----- _ ! 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 o the San Joaquin Local Health District. orl (Signed)----- v 5 - ------------- act -------------- -------------fss;m - � Title( ) ---- n(Plot plan, showing size of lot, location in relation to wells, buildings, etc., can be placed .on reverse side). ( 1 FOR DEPARTMENT USE ONLY p � APPLICATION ACCEPTED BY-------------------------------------------------------------------- ----------------------------- DATE------ l�___----_-• ------------------------------- DATE------------------------------------------------------------ BUILDING ATE------------------------------------------------------------ BUILDING PERMIT ISSUED---------------•------------- --------------------------- ---------------- DATE--------------------------------------------------------------- ---------------------------------------------------------------------------------- Alterations and/or recommendations:---------------------------------- ------------------------•--------------- ----•-------------•--------------•-------------------------------------- •----------------------------- -- -------------------------------------------------------- -------------------- •--- ----•--.._------•---•-------�- --------------------------------------------------------- " ---------------------------------- FINAL INSPECTION BY: -------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California - Lodi, California Manteca, California Tracy, California ES-9-2M , Revises 1.57 EP-CO.