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APPLICATION FOR SANITATION PERMIT Permit No. _---fO-7- T-_-_ F (Complete in Duplicate) Date Issued Applica4-ion is hereby made to the San Joaquin Local Health Dist •ct for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance 549 JOB ADDRESS AND L ATI ----- ----------------------------------- Owner's Name-.- ----- ------- ------------- Phone-,,- --•= - rAddress ---- -----------------------------------------------•------------- -------------- Contractor's Nam ------ --------- ------ F, ____ ----------------------------------------------- --------------------------- --•--- Phone.. = Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ,❑ Other ❑ �l� • 4 5 Number of living units:_/--- Number of bedrooms_- Number of, baths - ____. Lot size. _,Or _- Water Supply: .Public.system Community system ❑ Private ❑ Depth to Water Tabl C1ft. Character of soil to a depth of 3 feet:- Sand F] Gravel-❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFIC TIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.} + 4epLfic Ta Distance from nearest well_-__--_--------Distance from foundation--------------------Material---__---- -----_--_--_- ----------•-- No. of compartments---------- ---------------Size--------------=-----------------Liquid depth---------------- Capacity ` T �_ isposal Fie : Distance from nearest well-----------------Distance from foundation--____---------__-Distance to nearest lot line-_-_-_--_-__---_- # -------------------Length of each line--------------- I] Number o{ lines------------ =- Width of trench------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length--`--------I------------------------------ See}ppage Pit: Distance to nearest well- Distance f �__To dation��-------_-_.Distance to nearest lot line------ Number of pits.__-l--------------Lining material- -_ Size: iameter _- _I - - Depth--- f Cesspool: Distance from nearest wellDistance from foundation------------------- material------------------------------- •---- ❑ Size: Diameter _----------------------------iDepth-------------=----E--------------- Liquid Capacity gals. Privy: Dis+ante from nearest well---,.-,- -----------------------------------------_--------------------------�--Distance from nearest building ❑ Distance to nearest lot Ilne---------------------- -- , _. w ....� F i_eG Remodeling and/or repairing (describe)---------- - �/' - s ---------. ---•-------------------------------- - -- --- F y + yam. �. - pared this application and that the work will be done in accordance with San Joaquin County I hereby certify that I have pre ordinances, Sta s ..an ues nd`regulations of the San Joaquin Local Health District. (Signed)------ = l B ----_--- - --Owner and/or Contractor) t -------- ------------------------ ------ Y• _ - --------------------------------- ---- ------------------- -------------------Title - c y`" ............. (Plot plan, showing si of lot, location of system in relation to wells, buildings, etc., can be pl ed, ortaverse side). — a FOR DEPARTMENT USE'ONLY t APPLICATION ACCEPTED BY ---- - - DATE--_-----_='- --- _f_-'� ------------------------------ REVIEWED BY ----=- --------------'-----=----------------------------------------- DATE__± ' F �, .BUILDING PERMIT ISSUED-----------------?----------------- -- ---=------------------------------------------------ -------: DATE--`. .---••-------------- Alterations and/or recommendafions:_------_---------------- --------------------------•---------------------------- ------------ -------------------------------------------------- —� -----••----------•---- ------- ----- - -- T ---•----- ' ---- ----------•------------------------ - ---- ------------ -_.- -- ill FINAL INSPECTION BY---------- ----- -- -- - 9 4 _� V -.. x „,,� �. ,.. Date -------------------- SAN JOAQUIIV 1,OCAL°HEALTH DISTRICT e 130 South American Street 300 West Oak Street '-_ "' ^132 Sycamore Street �,R` 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California f E5-9-2M Revised W-2100-•-- ;