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11i _0 ' APPLICATION FOR SANITATION PERMIT Permit No. �. (l (Complete in Duplicate) /y f Date Issued -_,l_____ 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 L CATION----------- ------- - ----------------------------------------------------------------- y� � ------------ Phone--------------------•--------------- i Owner's Name---- `- ---- - ------------------------------------- Address----•--------- --------------- W Contractor's Name------------- ------ Phone----------------------------------- ----------------------------------------------------------------------- Installation will serve: Residence Ur Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ s ` ! Number of living units': .f Number of bedrooms --A. Number of baths __/__ Lot size _ W___.K1e0-______________________________ r Water Supply: Public system'[T�Community system El Private ❑ Depth to Water Table _' ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E-1-lardpan ❑ Previous Application Made: Yes ❑ No 2�New Construction: Yes ❑ No FHA/VA: Yes ❑ No Wj— TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__--"_____Distance from��foundation----Afe........Mater _______________ No. of compartments------A_____________ Liquid depth_____'y_. .........Capacity_____if�049-----. 0 � Dis osal Field: Distance from nearest well_______^.-----.Distance from foundati __ 2� ---__.__.Distance to nearest lot line___ ___________ per_ -1r L.� Number of lines------/__._____,_�___f_Length of each line----_- -�_____pp__ Width of french___�� ___________________ Type of filter material_/� _ - -Depth of filter material_____lf- e -.-Total length--------Q-- ---------------------- i Seepage Pit: Distance to nearest well---------~-------Distance f m f ndation___ r�_,____.Dr�tance to nearest lot line-- _____- Number of pits_______`_________Lining material___ __________________Size: Diameter__s„7_�_..---- ____.Depth-----A1.4__ Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material__._______________--____.________-___ Q ' .0 Size: Diameter---------------:----------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------__----------------------------- i ❑ Distance to nearest lot line--------------------------------- =--- ----- ' . Remodeling and/or repairing (describe} -------------------------------- :-------- -- -- 1 -------------------------------------------------------------•------------------- ---------------------------------------------------------------------------------------------------------------------•--•---------------- 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 rujols geu, ' ns of the San Joaquin Local Health District. (Si ned ---------------------------------------------------------------------- '{flwner„a Contractor) g )-------•--- ---- --- r ---(Title} '------------------------- BY� -------- ---------------------- (Plot plan, showing.size of lot, locm in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ------------------------ DATE--- Z --- APPLICATION ACCEPTED BY---------- - -- -- ---------------------- ---------- ------------- - ------- REVIEWEDBY------------------------ ----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-----------------------------------------------------------•----------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------ - --------------------- ----------------------------------------------•-------------------------------------------------- --------------------------- --------- �- — -------------------------------------------------------•---------------------------•---- --------------------- --------------------------------- ------------------------------- ----- ------ ---------------- -------------------- FINAL INSPECTION BY:. Date---- '--� ------------------------------------ SAN JOAQUIN 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 ES-4-2M Revisea 1.57 F.P,CO.