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APPLICATION FOR SANITATION PERMIT Permit No. .. ✓ /-_ - (Complete in Duplicate) Date Issued --------------- it � i Application is hereby made t'o the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with Coun Ordinance No. 549. F I� Q :- JOB ADDRESS AND LOCATION (------- 4_- d - -A ----- Phone-------------------•------ I Owner's Name Address.... '� ---...---- - ------d------------------------------------------------------•--------------------_-------------------•-------------•-- --- Contractor's - Contractor's Name--- _ - Phone -------- Installation will serve: Residence E- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ _ Number of bedrooms __0Y. Number of baths - _ Lot size __- - f �- r Water Supply: Public system Q�Commuriity system ❑ I�rivate ❑ Depth to Water Table .- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ElSandy Loam ElClay Loam 0 Clay ❑ Adobe Hardpan ❑ # Previous Application Made: ,Yes ❑ No ?'O' New Construction: Yes ❑ No [Lr FHA/VA: Yes ❑ No R _— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sep is Tank: Distance from nearesi.well-----------------Distance from foundation-------------------.Material------------------------------------------------- No. of comartme 3 p nfs--------------------------Size-------------------------------Liquid depth--------------------------Capacity-----------------------' Disp• I Field: Distance from nearest well-_____.-_--------Distance from foundation--------------------Distance to nearest lot line--_-----__----_- _: Number of lines_ ---------------------------------Length of each line------------------------------Width of trench---------•------- ------------.-- Type of filter material-------------------------Depth of filter material--------------------.__Total length----_---.------------ ---___-_-----_.---- �� S page Pit: Distance to nearest well------- '_________Distance f om undation----Xt--__-._..Distan�to nearest lot line---.44 ------- ( , --.Size: Diameter----- Depth--__ ., ------------------ Number of pits.----'--------------Lining material_ _ !I Ces ool: Distance::from nearest well-----------------Distance from foundation--------------.----.Lining ❑ Dia' material-__-__-----------__-------_-___._ Size: neter-------------------------------------- -.------------------•--------- --- -- ---------,_.-Liquid Capacity 9a ls. Privy: Distance from nearest well---__-----------------------------------------Distance from nearest building-------------------------------------_ y ❑ Distance to nearest lot line,-'----- ---- ---------------------------------------- ----- ------------------- Remodeling and/or repairing (describe)------------------------- <., -- ------------------------------------------------------------------ 444� -- ----------------=-------------------------------- -------------- ------------ --------------------------------------------------------------- i ------------•------------------------ ---------- ----------------------------------- ----------•------ -- -----------------------------------_-_------------- ------------------------- ------------------- ------------------------- I ---------------------- 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 r les and reg tions of the San Joaquin Local Health District. r (Signed)------------------- - • r-- --- - --------- ------- ----- ------------------------------------------------------------------------------ r Contractor) By: - ---�. --- Title -nw_ Y• ----------- (Title) f (Piot plan, showing size of Io , ca+ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- -------------- ---- - ----------------------------------------------------------- DATE---------------------------- •- J. I REVIEWED BY-- ---------- ------- .:. -- ---- ------------------ -----------------------=---------------- DATE------------------- : BUILDING PERMIT ISSUED---i ------------------ - -- ---- ---------------- DATE--------------- --t --/-�----- --Alterations and/or recommendations:_ __,_- ---------------------- 11 ---------------------------------------------- -;------------- _-- ------------------------------------------- •------------• r- i --------- --- - ----------------------------- ` A.----' 3 FINAL INSPECTION 'BY: �I - Date-----2"rr---------- - �i SAN JOAQUIN LOCAL HEALTH DISTRICT •, 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North •'C" Street Stockton, California Lodi, California Manteca, California Tracy, California i� r—7-21x1 , Reviser 1.57 F.P.CO.