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APPLICATION FOR SANITATION PERMIT Permit No. ._ ---------------- i �v (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 _ o-'_ � +4,f'�----[7-x�� Phone.__= -s _ -_ �� 6 Owner's Name---•----- -----••-----•- ----•--------�._�:..1'___ h�_�.Q------------------ ----- ---------------------- ------------- Address---------------------------------- r� "A •• �� D I�' ^ Phone Contractor's Name--------------------------- ' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms j- . Number of baths 1__.. Lot size ______ ______ �.- ?-------------------- ❑ ❑system Private Depth to Weterjable -------- ft. Water Supply: Public system )& Community " Character of soil to a depth of,3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe k, Hardpan ❑ Previous Application Made: Yes ❑ No J!�, New Construction: Yes ❑ No ❑ �c,., TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �c T nk: t Distance from nearest well______________ Material r ial------------------------------------------------- _Distance from foundation___-________ __.___. Capacity___________________- No. of compartments Size Liquid d�Pth ___� t -_-----._.-.Distance to nearest lot Disposal Field: Distance from nearest well_ ►1-�' Distance from foundation__ Number of lines------,�------ -_-- Length of each line__��_______. Width of trench._.��------------------ J €f---- _�� Total length-----4`—D--'-`•--------•-- Type or filter matenal__l�4,_ ?C— .__Depth of fiber material____---. Seepage Pit: Distance to nearest well_---------------------Distance from foundation-------------------.Distance to nearest lot line-__----- ❑ Number of pits----------------------Lining material--------- ------------Size: Diameter------------------ ----Depth--------------------------------- Cesspool: Distance from nearest wellDistance from foundation_....------.____---.Lining material-__--_------------------------------ ----------------- i r ❑ Size: Diameter---------------------------------------Depth---------------------------------------------- -- Liquid Capacity gals 'Privy: Distance from nearest well--------------------------------------------- ---Distance from nearest building------------- ----- --------------- ❑ Distance to nearest lot line------------------------------- Remodeling and/or repairing (describe:---- ------------- ----------------------------------------------------•------------ -------------------•-----------•-------------------•---- ��_f, ------------------------------------- _________________________ _______________________ __________________________________________________M1.__------___---...-____----____---.----_-_-.--..___-__-___--___-_.---_-------____----. ' e_________---------------------------- ---------- __________________________ _____________________.___-__----.--_------------ -------------------------- _.____.____ __ _ _ _ ___________________ ___________ _-------------------- I hereby,c rt y that I ha prepared th application and shat the work will be done in accordance with San Joaquin County ordinances, State rules add regulatt s i f the San J aquin Local Health District. - ----------- ----- --- --- ---------------- ------- (Signed) �dx Contractor) By:-------------------------- ---- ----- ----- -------- -------- -------- (Plot plan, showing size of lot, location of \tem in relay onto wells, building etc., can be placed on reverse side). J FOR, E�'ARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ ----------------------------------Il --;---------------------- DATE_::" /��,�Q �`S REVIEWED BY------------------ --------------- ----------- - ----------- ------------- -------------- ------------------- - -- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------- ----------------------:------ DATE------.-- f----------------- -------- --------------------- Alterations and/or recommendations: ---�• . =l----------------------------------------------- mmendations:_------ -�---�---�---�- -- ------ ---- -----------�- �-�--------- ------•----------------------•• - y # -- ` ----- -----------•---------------- 4---- !,z� FINAL INSPECTION ----- - Date-- -----jj -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American132 Sycamore Street 814 North "C" Street Street 300 West Oak Street Y Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2540