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4 APPLICATION FOR SANITATION PERMIT Permit No. __C_1---2-_�...._ .. (Complete in Duplicate) / S 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? ATION--- ------ --- =-------= - - ------------------------------------------------------------- ------------------------ - Owner's Nam ----- - ----- - ---------------------------- Phone_ - �j,r Add ress -----•---------------- /, -- - ---- Z Contractor's Name--- -- ---- / ----- - -- Phone�Of Installation will serve: Residenc11t Apart nt House ❑ Commercial ❑ Trailer`C;ourt ❑ Motel ❑ Number of living units: ___ _ Number of bedrooms ---,?- Number of baths _/___ Lot size ----- ----------------------- Water Supply: Public system` Community system ❑ Private ❑ Depth to Water Table/,�__�ff. E Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ -Adobe," Hardpan ❑ Previous Application Made: Yes ❑ No;K New Construction: Yes,K No ❑ FHA/VA: Yes ❑ Nom TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) #Disposal Distance from nearest well-----------------Distance from foundation--------------------Material_______________.___________________-____________- No. of compartments-------------------------Size--------------------------------Liquid depth-------------- - ---------Capacity...-------------------- e 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________._________________--___________--_Distance to nearest well_� -_____Distance from fo dation__,��_____.Distance to nearest lot line___ ____. ( Number of pits______t-------------Lining material_, _ __ _._..Size: Diameter__ -----------.Depth------- l Cesspool: Distance from nearest well_________________Distance from foundation._.___________.___Lining material______-______________________________ ❑ Size: Diameter------------------------- ---------- Depth---------------------------------- -----------------Liquid Capacify----------------------------5al-,N Privy: Distance from nearest well-------------------------------------------------- from nearest building.__._____-.-----------------------------_ ❑ Distance to nearest lot line------------------------------------------------ ---------------------------------------------------------------------------------------- Remodeling and/or repairing {describe): ` � __.___ __ __w.______ _ ` --- -- - --- - --- - - ------------ ------- ------ ---------------------- ------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- - I hereby certify that I have prepared this application and t t the work will be done in accordance with San Joaquin County ordinances,.Sfate laws n rules a_nA re a ions of f San quin cal Health District, i (Signed)----- -- ----------` -- -------- {Owner /or Contractor) Sy:...... ----- ---- --- - -- ---------------------------------- --------------- tion (Title} k. (Plot plan, sh size lot aof sem in relation to wells, buildings, etc., can be placed on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------��W�—0 "-------------------------------------------------------------------- DATE------ rr � REVIEWED BY DATE------- ------------------------------ BUILDING --------------------------- - BUILDINGPERMIT ISSUED-------------------------------------------------------------—-------------------------------------- DATE------------------------------------------------------------- Alterations and/or reco endations--------------------------------------------------------------------------------------------------------•---------------•--------------------------------------- -------------------------------------//X7- 1)F j4---------0_,K------------- �R F------.-----y-%,2-��------------------ ------ (K(� FINAL INSPEC N BY --_ Date-------------I__r- �J-- S - - 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-9-2M Revised 1-57 F.P.CO.