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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 Ordinance No- 549. / JOB ADDRESS AN OCATION- 1 Gil ! --------------------------.------------------------ Owner's Name---------- - �- ------ 11 ---r=�---------------------- ------ - --- -------------- Phone--------------------------------•--- Address-------------- ----------------------- ------------------------------------------- ----------- Contractor's Name `� ---------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---- Number of bedrooms --)-- Number of baths - _--_ Lot size --r--------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -7--el ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [�J-�New Construction: Yes ❑ No (— FHA/VA: Yes ❑ No ®— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) �ySep�: Distance from nearest well-----------------Distance from foundation-------------------Material__--_----------__---______-_-____----.------_. No. of compart l encs---- -- ----------------Size--------------------------------Liquid depth--------------------------Capacity..--------------------- Dispo al Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- *,�A' Number of lines-,,. fy :------------- -------------------Length of each line------------------------------Width of trench----:------------------------------ Type of filter material-------------------------Depth of filter material---------------------_Total length----_---.-_-______.____--_.-:----_----. y��,� �� i Seepage Pit: Distance to nearest Distance from foun tion___.__-__.-.---.Distance to nearest lot line----- -__.- [L}� Number of pits-- ----f-.----------Lining material t,—4 .� ------____-- p ��---------, ---- 1 ae: Diameter s� Dept Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----__________-_____-----------.-- ❑ Size: Diameter-=-4----------------------------------Depth---------------------------------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------_---.-----___-----.-----__- ❑ Distance to nearest lot line-- --- ----------------------- - ---------------------------------------------------------------------------------------------------------- �. Remodelingand/or repairing (describe)---------------0'�".�`____----- ( - ----------------------------------------------------------------- -----------------•----------•--------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------- \� \ --------------------------------------------------------------------=------•----------------------._--_-- -------------------------------------------------------------- ---------...------------------------------------ \ -------------------------------------------•----------------------------..----------------•---------------------------------------------------------------------------------------------------------------------------------- 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 ands regul ions of the San Joaquin Local Health District. Zll (Signed)-------------------- -- ---- ----- ------------------ ---------------------------------------------------- ------- Contractor) By:----------------------------------------------------• --v----------------------------(Title)---------�7 ' /71./__-------------------------- (Plot pian, showing size of lot, location of �einrelation to wells, buildings, etc., can be placed on reverse side). Fq DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----11- - - -M.-- ------ -- -W G)'L--------------------------------------- DATE--- REVIEWED BY --=------------------ - -------------------- DATE--------- BUILDING -------- BUILDING PERMIT ISSUED------------- I --------------------------------------------------------------- DATE------------------------------ Alterations and/or recommendationsi------------------------- -------------------------------•-------------------------------------------------------------------•------------------------------- ! -------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------I------------ - --- --- -- - - E-------- --- �-- -------------------------------------------------------- -- - --------- ---- -- ------ -------------------------------------------------- ------ ------------------------------------------------- 124c FINAL INSPECTION BY:- Date r/ ----------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reet 300 West Oak S+reo+ 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1-57 F.P.CO.