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1 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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 Or i ante No. 549. JOB ADDRESS A LOClATION.___�__ - ^�+ _ -- ---- ------------------------------------------------------------------------- Owner's Name ---- - Phone.,_... t�yy Address ,_.r_. . . -------- { = . Contractor's NarneJ., __ -_ ____. --- -� --- ------------------------------------� ------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ . Moteli❑ Othe�f Number of living units: ___I__ Number of bedrooms __ Number of baths -____ 'Lot size _____ _______________ x_ _ ___ Water Supply: -Public system -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 E] No @� New Constructon: Yes ®f No❑ FHA/VA: Yes ❑ No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is'available within 200 feet.) Septic a k: Distance from nearest well----------.------Distance from foundation--------------------Material-_____.________________--____-______.__________: l C;�Ri No. of c'om artments-----------"_______-------_-Size-_-----------------------------Liquid depth----_----i--------------_Ca Capacity f Disposal:Fiel : Distance from nearest well. �'[ ---Distance from foundaafio _'�p---___ p y Distance to nearest lot ImeF___�_______.. Number of lines------ .:, ,-._------•-•-=Length of each Iiia-_--- __-� -- -. _ Width of trench------, _c ----- Type of filter mater f + Depth of filter material_______ _ _______Total length___--_-_.__!! ._,._-______.____.___ p g Number of its--------------- --_ Lining mater -----------. "`^"'�_, .._Size:!Diamefer----_-------_--Deathst lot line --.---- Number e Pit: Distance to pnearest well__ __ ___g- Distance from foundation_________________ .Distance to p Cesspool: Distarce from nearest well____ -Distance from foundation__------------------Lining material___-----------.---____-____________-_. ❑ Size: Diameter----------------------------=J-----Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well.__/----------------_------------------------Distance from nearest building------------------------------------------ ++, ❑ Distance to nearest lot liQ'------------------------ ---------------------------------------------------------------------------- -------------------------------- � lin and/or repairing rt. Remode g p ( ------ ---------------------------°--------------------------------------------------------------------------------------------------------------- describe):_ - ------------------•----- --------------- ------------•----- ------------------------ --------------------------- --------------•-------•- --•---------------------- ---I——---------- --------------------------------------------------•---------------------•----------------•-•--•----------------------------------------------------------------•---•--------------•-------•-----------•--------------------- I hereby certify that I have prepared this application and that the work will be-done in accordance with San Joaquin County ordinances, StaWla1ws, ad rules and regulati s f the San oaquin Local Health District. J� " ------------------------------------------------------------Owner and/or Contractor5i red {Title)By:.------- ----------- - (Plot plan, showing siae of lot,Io ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- •------------------------------------------------------------------------------------------ DATE ------------------------------- REVIEWEDBY----------------------------- -� ------------------------------------------- DATE--- '---------------- ----------------------•------------ BUILDINGPERMIT ISSUED -----------------------=-------------------------------"---------------------------------- DATE-----!7j� ---------------------------------------------- Alterationsand/or recommendations:--------=--------=-----------------------------------------------------------------------•--•-------•--r„�--------------------------•------------------ ---------------------------------------------------------------------------------------------------------- --•-------------------------------------------------------------------------------------------•---- --------•----- S ` Y FINAL INSPECTION BY:__ __ ._._ -P Date------------- . _./I,- - ---------------------------- SAN JOA IN 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 E5-4-2M Revised 1-57 F.P.CO.