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APPLICATION FOR SANITATION PERMIT Permit No. _______________•......•. :01 (Complete in Duplicate) S l I Date Issued -------��---o =- � 11 Application is hereby mad( to the San Joaquin Local Health District for a permit to construct.and install the work herein described. This application is made in'+�compliance wit County Ordinance No. 549. �� JOB ADDRESS AND LO �"ATl - - - - ---'---- IN Ownor's Name -------- --------- - Phone------------------------------------ Owner's Address-------------- �II------ - - -- ------- ------------------------------------------ Contractor's Name----------- ------- --' -- ----- ------------------------------------------------------ Phone---------------------------------- Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ umber of bedrooms-__k-,-K—U�mber of baths __J.-- Lot size ------------------------------- Water Supply: Public sysf�m ElCommunity system T riva,te ❑ Depth to Water Table eft. Character of soil to a dep Ih of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No R-` New Construction: Yes [�N-o ❑ FHA/VA: Yes Flo ❑ ih TYPE OF INSTALLATION,IAND SPECIFICATIONS: (No septic tank or �esspool permitted if public sewer is available within 200 feet.) f Septic Tan Distance from nearest we I____ __Distance_Jr m foundation._..XP--------Ma erial____6_. No. oficom compartments --------------Size--� _. Liquid de th--- f Capacity / ----. :11p q P. p Y � Disposal F' d: DistanclIleI from neares well_.__'-__--:=---.-Distance''from foundation-_--.C__e --/--- Distance to nearest lot line-.-, _ NumbeF of lines------- ______' ength of each.line_. Ts --------Width of trench �� --------------------- Type of filter material_� �epth of{filter material _ ��:_._-_Total length___-..�r ____________________ Seepage P' Distan�e to nearest�wgell---------_-__Distance fr m��f�ou��}}dation- Ys--------Di tante to nearest lot p g Numbe� of pits__.__cr ___._.._.Lining material__. C� �.Size: Diameter___ .-__Depth_ `----/_l _/ ,e \ Cesspool: Distance from nearest .well-----------------Distance from foundation--------------_---- Lining material---------------------------------- ._. \ [ ih ❑ size: Diameter - f'-------- - ------Depth--------------------- ---- ------Liquid Capacity--------------------------•gals. ' IIII Privy: Distance from nearest- well-----------------------------------------------.-Distance from neares+ building------------------------------------------ ` ElDistanche to nearest lot line------------------- ---------------------------- --------------------- ------ ---------------------------------------------------- Remodeling and' repairing (describe):"---: --------- -- J- ----•-- ---------------------------------------------------------- _ --- �� ---------------•------------------ -------------------------------------- ----------------------------------------------- -----------=--'------.__.-------------------------.------.._.------------------------------------------.--------.------------------------------------------.---------------- I hereby certify that ;have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rule nd regulations of the San Joaquin Local Health District. Si ned 9 } r -----------------------------------------( Contractor) BY:---------------_--- III -----------�----------- [-Title):-= �'��' (Plot plan, showing size of of, Iota ' o system in relation to wells, buildings, etc., can-be placed on reverse side). A A FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------10--- ---------------------------------------------------------- DATE----- -- - REVIEWEDBY------------------ h---------------------------------- -----------------------I--- ------ DATE--------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------- ---------------------------- DATE------------------------------------------------------------- Alterationsand/or recom endations-------------------------------- --------------- ----------------------------------------------------•------------------------ .-- --- --•-----•-- -------- == InIIa-------b ar s-------7 �_ r� b----- ` cav -T --y�------------- -------------------------------------------------- --1-------------------------- 7... ._S _iT.T(-. nN, b.P4-K_S--� ....k�pCf=1--------O'K--�----- � "��5f �{ K,q--------------07--'-0- �}?`�'•-------- ----------------- ------------------------------- -- --------- --------- ------- :-----------------•-------------------- i ul - p FINAL INSPECT- ----- ----- -- Date_. sY�--------------------------------------------- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 13o South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-4--21x1 ,J Revisea 1-57 FRCO.