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APPLICATION FOR SANITATION PERMIT Permit No. ....�a.. .S.s, (Complete in Duplicate) This Permit Expires i Year From Date Issued Date Issued .------- Application is pp 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.. ---------------•---•--•----- Owner's Name-------- , A_____ ____ �TL11 Z-- ----------------------- -------------------- ---- Phone_. - - �". Address-------.....-----. -------- ---------- - ----------------- Contractor's - Name----- •------r ........ / --_2 � --- Phon Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [-I Other ❑ Number of living units: -_ -.- Number of bedrooms -7 -- Number of baths _- Lot size -_----:.�. _- -/2 ------- Water Supply: Public system f Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3\feet: Sand.C] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No FHA/VA: Yes ❑ N TYPE OF INSTALLATION AND SPECT I ATIONS: (No septic tank or cesspool permitt d if public sewer is available within 200 feet.) tk Distance from nearest well_ -r_ Distance from foundation---- - Material_-.. - _. No. of compartments--------------------------Size-------•----------------------.-Liquid depth--------------------------Capacity----------------------- Dispos Fie d: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot� line----------------- Number of lines----_------yLength h l .----------._--.-----.-Len toeacine.._-----_-.� 9 -------------------Width of trench-------------.-----------------•-- Type of filter material-------------------------Depth of filter material-----------------------Total length----_----_-------_--.--_---_---_-------.- SeeRa .Distance to near _est well.-. - _1J&C f°--Distance, om undation---/ ----------Distance to nearest lot line- ---------- /,V�W � Number of its------ Lining material-_-110-e , --_---..Size: Diameter- -----r-------Depth--- ----------------- Cesspool: --- -----------Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material----.-_----------_.----_-.-__------- \, ❑ Size: Diameter------------------ -------------------Depth--------------------- -----------------------------Liquid Capacity-------------------f-------gals. Privy: Distance from nearest well------------------------------_------------.----Distance from nearest building--------_---_._----_- .-__.-.--.-------- ❑ Distance to nearest lot line-- -------------- ---------------------------- ------------- Remodeling and/or repairing (describe}- - - - - ---- [�-� _- - - ,-,� - --- - -- - - --------------- -------------------- E . ---------- - - ----,� �th - = - ----- ------- ------ f ------- ------------------------------------ --------------------------------------------- - ----- - I hereby certI have prepare his a kation and that the work will be done in accordance with San Joaquin County ordinances, State laws rul nd gula+' s of the San Joaquin Local Health District. (Signed)-------------- p _ - -- ----- - --- ------------ --- -------------------------------- Owner and/or Contractor) BY: f--(Title) ---------------- (Plot plan, showing size of lot, location of system in rel ion to wells, buildings, , can be placed on reverse side). FOR DEPA TMENT USE ONLY APPLICATION ACCEPTED BY-.- -------------••----------------------- DATE------------- -`. REVIEWED BY ----------------------- DATE BUILDING PERMIT ISSUED----------------- --------------------------------------------- DATE---- --- ------ ---- Alterations and/or recommend'ations:_-, -- .- .- -_3-..--'--_., --- ---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ -------- ----------- ------------ ----------------------------------------------------------------------------------------------- ----------------------------------------------------- -------------------------------------------------------------- ---------------------------------------------------------------------------------.-------------------------------------------------------------------------- ------------------------------------ FINAL INSPECTION U ------------- - ---- ------------- 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 FS-9-2M Revised U59 F.P.Co.