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�J APPLICATION FOR SANITATION PERMIT Permit No. .-1_! _G. (Complete in Duplicate} 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 LOCATION--- -------__--- __- 9 ------ ------------------------------------.------------.------------ --------- Owner's Name------------- .-• - ---=------------------------- - Pone------------ '� Address--------•--------I. --�------�------- ----------- ------------------------ -------------------•------------------------------------------------------------- - ---- - --- - Contractor's Name------------------ _ - --- - -------- ----------- ----- Phone-----•--------------------- - ----- Installation will serve: Residence �Apartmenf House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _ -- Number of bedrooms _-, - Number of b -----_ aths _- Lot size __ El Supply; Public system E]— Community system ❑ Private ❑ Depth to Water Table A69 tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �rdpan ❑ _•.. Previous Application Made: Yes ❑ No P�'New Construction: Yes ❑ No 2?'FNA/VA: Yes ❑ No [*}•� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearesi well------------------Distance from foundation-------------------- ❑ No. of compartments--- ------Size--------------------------------Liquid depth----------- - ----- Capacity-------------------- Disposal Field: Distance from,nearest well-_ 'Distance from foundation. -__ - f�_-_-Distance to nearest lot line---��____ Number of lines-_-__--_/----------------- Length of each line-------- ----Width of trench------- �/ Type of filter material_-- _ Depth of filter material_-_--,1 !?-----Total length------_-. �'-_-_--_ __ Seepa e P't: Distance to nearest well • - �-Distance from fo dation___..�e------- Distance to nearest lot line---_.5�---_ �1 Number of pits-------/------_---Lining material-_ -__Size: Diameter--_-- `` ' ,2- De to---- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----_-.-_-____-- ____-_____ ----- ❑ Size: Diameter -- t - ------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well--._---___-------------- from nearest buildin » Distance to nearest lot line _ ------ ---------------------------------------------------- Remodeling and/or repairing (describe)-------------------- --- -�'� - ---------------------- -- ----------------------------------- ------------ --------------------------------------- I - I --•-------------------•-----------•-------------------------•------------•-------------------------------------- 7 ------------------------ -------•-------------------------------------------------------------------------------•---------•-------------------------------- *"r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations ofAfe San Joaquin Local Health District. Si ned t%�� (Signed) '� ------------------ - - ---------- - � -- - --- ------------ ----------•--------------------------------------------------------{0WA&&-mwl/-,or Contractor) By:------------------------------------•---------- -- ------ -------------- -----------------------------(Title)------------- (Plot plan, showing size of lot, locati o system in relation to wells, buildings, efc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y_---- DATE-_-_- ------- REVIEWED BY--------- _ .S ��► ------ --- - ------ ------------------------------------------------------------- REVIEWED BY-------- --------------------- - S--------------------------------- ------------------ ----- ---- DATE -- -------------------------------------------------- BUILDING PERMIT ISSUED------------------------------ - -------------•-------- DATE ---------------------------------------------- Aiterafjons and/or recommendations:-_----_._-._-_--. ------ __ _ _ _ � _�----------- - �. ----------- ------------------------- --------------------------------•------------------------- -- -------------- ------- ---- --- - -- - -- --- ---------------------•-----------..-----•------------------------------------------------ --------------------------------------------- 1 F FINAL INSPECTION BY:---- . __ ------/Y"-- Date-------- - �- ---�-�.�J .- . ,SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 Wes+ Oafs Street 132 Sycamore Street # — 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California � ES-9-2M Revised 1-57 F.P.CO. #