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APPLICATION FOR SANITATION PERMIT Permit N a. (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 Ordinance`No. 549. JOB ADDRESS AND LOCATION_ --------A-77-/--------------------------------------------------=---------------------------------- ------------------------------- - ---- Owners Name----- Address ------- -----------------------••------------------------------------------ -------- ------------ Contractor's Name._ -- �` ---- "f'r -• -------------- -- ------------- Phone----------------------------------- ya` Installation will serve: Residence "Apartment House'❑ Commercial ❑ Trailer Court ❑ Motel ❑ • Other ❑ Number of living units: --Z-- Number of bedrooms :_/--._ Number of baths __f.__ Lot size _ %� Water Supply: Public system ❑- Community system ❑" Private R�epth to Water Table Ife ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ "Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [< New Construction: Yes ❑ No I FHA/VA: Yes ❑. No E�` TYPE OF INSTALLATION AND SPECIFICATIONS: { (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) t Set Tank: Distance from nearest welf_____-_.___ Sep Distance from foundation--------------------Material____.__-______--_---__-.______•---------- ----, No. of compartments----------"- ----------Size--------- =-------------Liquid depth_- -----------------------Capacity [Y Dis qsa Field: Distance from nearest well-----------------Distance from foundation---------------------Distance to nearest lot line____.___._.............. Number of lines-----f_----s---------------------'-Length of each line------ -----------------------Width of trench------------------------,---------- Type of filter material------------ "-------'_Depth of filter material ___.___----____}______Total length------'_-_--___-______._______--________ .4 de Seepage Pit: Distance to neares+'well-/-/, '___:__'_Distance from faun ation--�,0-,.__....Distance to nearest lot line__t� �____ Number of pits___________-____Lining material/�-;Size: Diameter__ _-----____-Depth.__:A ---------------------- Cesspool: `______- - Cesspool: Distance from nearest.well-____________:_Distance from foundation--------- .a_____-Lining material--------.---------------------------- " t. : ❑ Size: Diameter-----= ---------------------------- 'Depth----------------------------------------------------- ---------------------- -- L.iquid Capacity----------------------------gals. Privy: Distance from nearest well------_-------------------------------------------Distance from nearest building__ ___:________-____-_-____________ ❑ Distance to nearest lot line- I. _ . - ------------------------------------------------------------- -- -- Remodeiing and/or repairing (describe) l - -= ------------------------ ---------------------------•------------------------- . i ------------------------------------------------------------------------•-----,-----------------------------------------f----------------•---------=-------=-------------------------• - ------------------ ------•-•-•---- ---------•--------- -------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin County a ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Si ned g ----[CkyajEt2ttjd/-or Contractor)By: -- ----- --- {Title)- ,� I (Plot plan, showing size of lot, locati f system in relation to wells, buildings, etc., can be placed on reve se side)) FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- -------------- -------------------------------------------------------- DATE_ - --------------- ---------------------------- R EV I EW ED BY------------------ -------- ------------- ----- DATE--- -------------- BUILDING PERMIT ISSUED------------ Z� -------------------------------------------------------------------------------- DATE-----_,__-tom Alterations and/or recommendations:--------=--------------------- ---------------------------------------•----•------ ----------pk- --------------------------------------------- -------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------- -----•----------------•-----------------------------------------------------------------:------------------------------------------------------- ---------------------------------------------------•---------------. ------ --------------------------- ------------------------------------------•------------------------------- •------------ ----------------------------------------------------- --------------------------------------------- FINAL --------------------------FINAL INSPECTIONBY:__:-�j'-.-:-- -"- - ��-- --------- [ m. ._._ �__ Date :_. -------- SAN JOAQUIN LOCAL HEALTH DISTRICT Street 130 South American Streef ,t 300 West Oafs t 132 Sycamore Street 814 North "C" Street Stockton, California i Lodi, California Manteca, California , Tracy, California y ES-4-2m Revisea 1-57 F-P.CO.