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APPLICATION FOR SANITATION PERMIT Permit No. J/. _#0___,1---- (Complete #0_1___ ' (Complete in Duplicate) l/(o Date Issued ____I__t_-_ ..f- 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. ,yy JOB ADDRESS AND LOCATION `3 G- -`--------------------------------- Owner's Name Phone --------------------- Address-------- -------------------------------------------------------------------------------------------------------------------�---------------17 Contractor's ..Name ---------------------- i� . Phone, �l/`�---- Installation will serve: Residence Q Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Number of bedrooms -3__. Number of baths _v _ Lot size __. -------- --------------------- Water Supply: Public system ❑ {Community system ❑ IPrivate EEr'_Depth to Water Table .y4? ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 3r"�Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes ❑ No D-�'_FHA/VA: Yes ❑ No El �. TYPE OF INSTALLATION ANb SPEClFlCATIONS: (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) Distance ..from nearest well ----------------- Distance from foundation -------------- ------ Material _____________________._______________-._..__-_-- No. of compartments----------- --`---- ---- Size ------- - -------------------- --- Liquid depth -------------------------- Capacity ----------------------- Dtsposal F' Id: Seepage Distance from nearest weli_�_�_.�..Distance from foundation ------ %¢:-__-_.Distance to nearest lot line__l�-s_____._ Number of lines ------- ___)--_ ___-_-_yyJJ- -._��_ Length of each lin e ------ _3! -------------- .Width of trench___-� 5K ------ _________ Type of filter material____S_I_! � Depth of filter material ---------__.Total length ----- &d________________________ - Distance to nearesfwell --- ,�0-___---_--Distance�f f undation_-- lC�_____=....Distance to nearest lot line_________________ Number of pits______ ____________Linin material___-/-/ ___.Size: Diameter _____________Depth____o_�___-________..___._ )nearest Cesspool: ElSize: Distance from well ----------------- Diameter-------------------------- ------------- from foundation ------------ .------- Lining material ________________.________________ Depth ----------------------------=----------------------- Liquid Capacity ----------------------------- gals. Privy: ❑ Distance from nearest well ------------------------------------------------- Distance to nearest lot line --------------------------------------------------------------------------------------------------------------------------------------- Distance from nearest building _____._______-._------_--_------_________- ----- Remodeling and/or repairing (describe): --------- -----------------------------------------------•------- ----------------------- ------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- -------------------------------------------------------- --------------------------- ---------------------------•------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- 1 hereby that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, �f�afelas, and rules and regulations of the San Joaquin Local Health District. (Signed)-----------' S ------------------- -------------------------------------- --- ---------------------(Owner and/or Contractor) B f M1 (Title) Co_s-�-------------------------------------- Y---------------- - (Plot plan, showing size of lot, location/of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY C_' ----------- ------------- DATE ------- 1-�!_ �1` _ REVIEWED BY------------------------------------------------------------------------------------------------------------------------ --- DATE----------------------------------- ----------------------- BUILDINGPERMIT ISSUED----------------------•------------------------------------- --------------------------------------- DATE ------------------------------------------------------------- Alterationsand/or recommendations: ------------------------------------------------------------------------------------------------------------------------------------------- ------------------- --------------------------------------- ------------------------------- ------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------- ----------------- - ------ ---- --- -- -------------------------------------------------------------------------------------------------------------------- FINAL INSPECT N BY------ --- - - ------------ Date --------'-`5 ---- i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised 1-57 F.P.CO. G) N l