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APPLICATION FOR SANITATION PERMIT Permit No. .•�`.. .:. - y (Complete in Duplicate) y y yf Date...Issued r-------- ------------- Applica¢ion 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 LMAtTl ON__ _ _-_ (,�___.___ .�__._Owner's Name---------------- - '.& . Phone- ----------------------- Address hone. _ � Address-----------4-------••-•--------------- m -------7 �l'h.Q----------�--------'-------------=---------•----•-------------=--�-----•�------- Contractor's Name---------------------• :._ --------- -------;----------•--•-- --------`---------------•-•-- Phone----�._f-46_7 Installation will serve: Residence Apartment House ❑ Commercial.❑ Trailer Court ❑ Motel ❑ Other ❑r Number of living units: _f.-- Number of bedrooms __�IClumber of baths ---L. Lot,size Water'Supply: Public.system 2r_6ommunity system ❑ Private ❑ Depth to`Water Table1�t. Character of soil to a depth of 3 feet: ' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe©--Hardpan ❑ 1 Previous Application Made: Yes ❑ No �lew Construction: Yes ❑ No ❑ �,�, � E(No F INSTALLATION AND SPECIFICATIONS: r septic tank or cesspool permitted if public sewer is available within-200 feet.) Distance from nearest well_'_____ `_''___D;sfance from foundation_._..._�------.__.Material_________________________._____--__-_______-__. No. of compartments---- --------------- ----'Size-----------------------"----------Liquid-depth--------------------- ----Capacity I Pi Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line------._._____--- Number of lines'--- ----------------------------Length of each line------------------------ Width of french----------------------------------- Type of filter material-------------------------Depth of filter maferial_____--_.-__________._Total length_______•-__________..._________-______-- Seepage Pi Distance to nearest.well-fir_jQCDisfance fr foundation_/,O...-'.._..Distance to nearest lot line___ -------- (n Number of its._. __!_ _ __Linin material ____`- _� . ") p / --- -- g �I ---.Size: Diameter-- ---{------..De th--- Cesspool: Distance from nearest well------------------Distance from foundation----------- -- ---Lining material_ tY-----_ _ _ _ __,_________-_____________ ____ "� ❑ Size: Diameter-------- - = q P ----------------- ------' Depth---------------------------------------------------Liquid Ca aci ------------------- gels. Privy:` Distance from nearest well------_-------_-------------------------------- Distance from nearest building-____----__-___________-.___----------__- ❑ Distance to nearest lot line____________'__._--_ Remodeling and/or repairing (describe)=----------------------------------------------------- ---------•-----=---------------------------- ----------- -------------------•----------------------•-----------------•-------------------------------------- --- ---------------•---------------------------------------------------•---------- ---•--- ----------------------- -------- -------•------------------------- ---------------------•---•- ---------•--------------- I;here cert- y t I have prepared this ap lica 'on and that the wor will be done in accordance with San Joaquin County ordinances, Stal laws, ad rules a&d re I tions of+he San Joa ' Local Health District. (Signed)_•-•------- --- --------- o -- Contractor) s _ _______________i f BY:----- --- --------------------- - " -- ---(Title)- - -� - { (Plot plan, showing size of lot, location of system in re ation to w s, bpi ildings, etc a be ace on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED. BY - -----•------------------------------------------------------------------------ DAT .......... REVIEWEDBY---------•----------------- ------------------------------------------------•--------------------------------------- DATE_._gN -------------------------------------------------- BUILDING ----------------------•--------------------•-•-- BUILDING PERMIT ISSUED--------=- - -------------------------------------------------------------------------------- DATE -�- Alterations and/or recommendations----------------------_--------------------------------------------------------- -•--••------------••---•-----------------------------•-----••------------------•-•----------- --------------- ------------------------------------------- --------------------------------------- -------------•--------- -------------------------------- •------------------------ ----•--------•---------•-•-- FINAL INSPECTION BY:_. .- - J 7 � - - - - . � . 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 E5�4;- Revised W-2100