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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in 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 -AMNO' LOCATION Owner's Name-- l"" ! 4T--------�--� � 3" ----- Phone Address---------- -------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------•----- Contractor's Name------------------------------------------------------------------------------------------------------------ --------------------------------- Phone---------------------------------- Installation will serve: Residence;K Apartment House ❑ Commercial (] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J---- Number of bedrooms __ ---- Number of baths -1----- Lot size ______.___________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table __ F_ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No Q1__ New Construction: Yes No ❑ FHA/VA: Yes ❑ N 0156 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___ 1'�._--__Distance from_fou�,dation_--/A ________.Materi �Zw_No. of com artments_____.- ---_ ________Size___ � Li uid / Ca acit C� Disposal Field: Distance from nearest well_.; 0______Distance from foundation---0__53" ___.__Distance to nearest lot line_____-ti_--___-__ Number of lines-----I---'_-- -- Length of each line-----'..fl----------------Width offrench-_,;;.---- of filter material-- ._ ___Depth of filter material--4?-------------- length_______;<76 I Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ i ❑ Number of pits-------#-------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: -------------- ------Cesspool: Distance from nearest well-----------------Distance from foundation-- -----------.-----Lining material-_._______________.____------______- ❑ Size: Diameter------------------ ----------- ------Depth-----------------------------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well ____-___.____________________________"---------Distance from nearest building _-_________-____._____-- ❑ Distance to nearest lot line--'1!P------------- ----------------------------------------------------------------•--------------------- ---------------------------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- I 1 -� ------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta aws, and rules and regulations f the San Joaquin Local Health District. (Signed) f - r(/, `� '� F ' ----------------------- - - ----------------------------(Owner and/or Contractor) By:---------------------------------------------------- -------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- wT------ ----- � DATE .,r �. REVIEWED BY:- =-------------------------' -----`--- = � f DATE---,,, -' �Y-1- BUILDING �r PERMITISSUED------------------------- --------$ -�1/_�-- ----------- -- --------- DATE------------------------------------------------------------ Alterationsand/or recommendations-------- ------/Y---------------------/---------•------------------------------------------------------------------------------------------------------- ---------------- ---------------------------------------------------------------------------------------------------------------------- -----------------------------------.-------------------------------------------- ---------------------------------------------------------------- -------------------------- -----------------------------------------------------------------------------•...... -------------------------- ---------------------------------------------------------------------------- •--•-•--------------------- ------------------------------------------------ ------------------------------------------------------------------ ---------------------- -------------------- ------------------------- -------- -------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:--._ ___y -- --- -- ------ .......--- . ------ Date---- I: SA JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P.CO.