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APPLICATION FOR SANITATION PERMIT Permit,&[ (Complete in Duplicate) Date Issued ---- This Permit Expires 1 Year From 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 ANODOCATION-------------- ---- -- ----- --- --------------------- --------------- --------------- ------------------------- Owner's Name---------- Phone-, of Address__-_--------------------- ----- ------------------------------------------------------------------------------------ Contractor's Name...... -------41�:---------- Phone-_x0e---lzw.;� Installation will serve: Residence R!( Apartment House ❑ Commercial E] Trailer Court El Motel El Other E] Number of living units: --I--- Number of bedrooms -e---- Number of baths Lot ze._ -----loc. Water Supply: Public system 12rCommunity system [I Private E] Depth to Water Tableja ft- Character of soil to a depth of 3 feet: Sand [—] Gravel E] Sandy Loam 0 Clay Loam F] Clay E] AclobeOl Hardpan"[3 Previous Application Made: Yes E] No JW,- New Construction: Yes E] No FHA/VA: Yes E] N0_121_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se lgR Tank: Distance from'-nearesf w.e.1.1------------------Distance-from fou.ndation-------------------Material-------------- No. of compartments--------------------- ----Size--------------- ---------------Liquid depth----------------- --------Capacity----------------------- Di -------Capacity----------------------- I D' I Field: Distance frominearesf Distance from foundation--- ---------Distance to nearest lot line-----S...... Number'of lines_ ---Length of each line---9 _Ij ......" /0-----------------Width of P,A-J,— Type of filter material__ - -y Depth of filter material----------IS-II---Total length- ----------------ic Seepage Pit: Distance to nearest wellil�r� 011 - -----I�istance from founclation-_/19 Distance to nearest lot V1_ Number of pits.-.-I-----------------Lining material----------Size: Diameter-----3-j// ---.Depth-------a_0----!n.......... Cesspool: Distance from nearest well-----------------Distance from foundation__.._._.-.__-__. _..Lining material_____..----__--____________________- 11 Size.: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from,nearest well--------------------------------- -------------Distance from nearest,building------------------------------------------ Distance to nearest lot line---- - -------------------- Remodeling and/or repairing fclescribe):--------- - ------------------- ---------------- ----------------------------------- ------------•--------------------------------------------- --- --- ----- ----y------- --------------- �---------------------------------------------------------•------------------------ --- --- -------------------------------- - ------------ --------------------------------------- --------- ------------------------------- - ---------------------------------------------------------- - -------------------------------------------------- --------=---------•-------------------------------- I hereby certify that I have prepared this application and that the work ill be done in accordance with San Joaquin County ordinances St t laws, and rules and regulations of the San Joa.quin Lo al Health District. St L (Signed)- U------ ---- ---- ------------------------- 2ffi0$br Contractor) By:-----------------------------------------I---------------- ---- - -- ------------- --------- ---------------------------(Title)---------------------- --------------------- - -------------- (Plot plan, showing size of lot, location of system relation to wells, uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------—7—t_tRI�P-------- -------------- ----------- -----------------. DATE----------- t ---------------- ------------- REVIEWEDBY------------------------------------ -- _----------------------------------------------------------------------------------- DATE -------------------------- BUILDING PERMIT ISSUED--------------------------------------------------------• - —-------------------------------------- DATE Alterationsand/or recommendations:----•----------------------------------- ---- ---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- ----------- -------------- ------- -----------------------------------------------------------------------_----------------------------------------------------- ---------------- --------------------------- ------- ------ - -----------------------------_-------------------- - ---------- ----------------------------------- --------------- --- --- --•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - FINAL INSPECTI ---- ---- ---- - Date.----- --- -- --------- - --------------------------------------------- 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,PLCC.