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APPLICATION FOR SANITATION PERMIT Permit No- ___._/i__"Z.a/...._.. (Complete in Duplicate) 1i(�/1 1 j'} r Date Issued ____/1--.�/____ _ Applica+ion 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"___--t_ V F -----'-- •• '' •� �� Owner's Name__--��- t--- __ Phone - -- --- ----•------------•----- --------------- ---- ------ ------ -------- ------ ---- ----- ------------ ------------------------------------------ Contractor's Name___ - ---� Phonl.,1 f 6 4.4 Installation will serve: Residence L;-.I �artment House ❑ Commercial ❑ Trailer Court ❑ !!Motel ❑ Other ❑ Number of living units: __1-__ Number of bedrooms Number of baths --____ Lot size _=---4r_Q---._ __,.Z" "O1_____""-"""""-".""-_ Water Supply: Public system A --Community system ❑ Private,��epth to Water Table � ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S�alFi� tiTan - Distance from nearest well__;______.___.__Distance from foundation_-----__"._.-__._..Material_-.-."_"""""."__-..______________________....... --- ---- Liquid depth-------------------------Capacity----------------------No. of compartments-------------------- - ---Size------------""""-- ""Distance from nearest well..rS.�.d_�--Distance from foundation_-_ 74?--- ----Distance to nearest lot line._" s_A------ �.� Number of lines__________ Length of each line-----/--a---!..--- .Width of french...._�y_"r'._.._.._-______ Type of filter material._..!.#__._ __ - _Depth of filter material------/_k._---_._Total length""- f/-0--•_._-____-______--._ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_.______-__._____ ❑ Number of pits----------------------Lining material------ ------------Size: Diameter-----------------------Depth------------------------- Cesspool: Distance from nearest well----------.------Distance from foundation--------------------Lining material-".-- -------------------------------- F1 ____--_-...__._.__._-_____ __.❑ Size: Diameter------- ---------_------------- ----Depth------- - -------------------------- - -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well -".....------------------------------------.----Distance from nearest building--------------------------------._._-----. ❑ Distance to nearest lot line--------------- - ----------- ---------------------------------------------------------------------------------------- ------------------- -- Remodelingand/or repairing (describe):-------- ---------------------------- -----------------------•-•-----------•------------------- --------------------------------------------•---------- ------- ---------------- --------- -----------------------•------------------------------ -------------------------------------------------------------•-------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta law and rule nd re ulations of t San Joaquin Local Health District. (Signed)------ -•• - -------------- ------- "------------ - yet Contractor) ---- -- ------- - - BY� / ------------- {Title)- a'f1` (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 APPLICATION ACCEPTED BY.. --- ------- ---- -- - -----------------------------------------------------------• DATE'��._ _------------ ------------ ------- REVIEWEDBY--------------------------------- -------- ---- DATE =v I BUILDING PERMIT ISSUED-------------------------------- ------- -------------------------- DATE------� ------------------ Alterationsand/or recommendations:------------------------- ------------------- --------------------------------------------------------------------------------------------------------------- ------------------------------------------------- -- ---------------------------------------------------------- -----------------------I-------------•-••-----------•-- ----•-------•----•---------------------- ------------------------------------------------------------- ------------------------"----- --- ----------•------------------------------------------------------------ / s- —V �y FINALINSPECTION BY:..------- - 5-"--------- --------------------- Date----- ------- ------ -------I------------------------------------ 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 J-2M 14GA46 ATWCOD 12-54