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f r.q, I APPLICATION FOR SANITATION PERMIT Permit I (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ___ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein dre�scribed. This application is made,in_compliance�w'.h-County Ordinance o. 549. JOB ADDRESS AND LOGON -` Owner's Name----- \ - ------------------------------------------ ---- -- -------- -------- --------- Phone Address - -- --------------------•----------- Contractor's Name- � Installation will serve: esidence [IApartment House ❑ Co mercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms _------- Number of baths _"L---_ Lot size Water Supply: Public system - ---- --------- -- PP Y� y ❑ Community system ❑ Private ❑ Depth to Water Table -s--- ft. Character of soil to a depth of 3 feet: Sand V] Gravel [] Sandy Loam ❑ Clay Loam ❑ Gay ❑ Adobe ❑w Hardpan ❑ Previous Application Made. Yes [❑ No Yom' New Consfruction: Yes_& No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t.. Septic Tank: Distance from nearest well-- -----Distance from f upp ation---�' `------.Material No. of compartments----------------------Size - - - Liquid depth-----� --- ----- -----Capacity ---------- _ , Disposal Field: Distance from nearest-we11_e (Q." "-.--Distance from foundafion"" 3" .""""-".Distance to nearest Cot line" Number it lines---------af ---Length of each line-----LZ,7`_---__----_.-.Width of trench-..�-q-`------_ ^; Type of filter materia y --------- --- - - -��-F------Depth of filter material-- -��-- - -----.Total length----�-��--------------------- ------ Seepage Pit: Distance to nearest well_--------------------Distance from foundation_---_-__--____-__-.Distance to nearest loft❑ lineNumber of pits---------------------Lining material-----------------------Size: Diameter ------ ""-. "-_ aj ----. p - ------------------------ Cesspool: Distance from nearest well-_"--------------Distance from foundation- _----- Lining material--------Size: Diameter -------------------------Depth---------------------------------------- ---------Liquid Capacity------------•- --- .-gals. ----- Privy: Distance from nearest well.".- "_."__._""_-.-."Distance from nearesfi building__ ----- ------ ❑ Distance to nearet lot I,ne--.---_--------------------- ---------------------------------------------------------------------- Remodeling -------------------------------- Remodeling and/or repairing (describe):----"- ". r ---•-------------------------------- -------------------------------- -------------------------------------------------- ------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------•--------"------ -------------- I hereby certify that I have prepared fhis7applicafion and that the work will be done in accordance with San Joaquin ounty ordinances, Stat laws, a d rules and regulations of the San Joaquin Local Health District. C -. Signed)- -- ------ ----- ---- --- - "' "-- --Owner and BY�-------=----- r Contractor) [ /o (Plot plan, showing size of lot, ocatio#of system in re afion-to wells- buildings efc."-A—6e placed--'o--n-----r-6-v--e--r--s- on-reve-rse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_. ._ DATE f`l,�''�l� r REVIEWED BY------------ I - ------------------------- DATE-------------------------------------------------------------- ------------------ - - UILDING PERMIT ISSUED-------------•---------------- - ------------------------------------ DATE. Alterations and/or recommendations:-- ------------------------------- ---"-----•-------------•---------------------- --------------------------- - •-•-------- ---------"---- ----------------- ------ --- - ----------- ---------------------------------------•-------•-------------------•---------- ------------------------------------ FINAL INSPECTION BY:-- . .." ." �y - ------------ Date-- .J...__ � 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 8-'59 F,P.Cu.