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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) w/ - pate 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. A e JOB ADDRESS A LOCATION --- ------- lf Owner's Name_____ __�___�J�__1- i -- -• --------- -•-----------•- ------------------ -------------------------- Phone-------------------------- --- --- 1 -------------- Address +� - - y ----------------------------------------- Contractor's -- -------------------------------------- Contractor's Name----------------- ------------------------ ------ Phone----•---•-------------------------- - --------------------------- Installation will serve: Residence Apartment House Commercial ❑ p ❑ ❑ Trailef C ur ❑ ,M,ptel ❑ Other Number of living units: _1_____ Number of bedrooms __ � Number of ba t ze Water Supply: Public system ❑ Community system ❑ PrivateA Depth to Water Table ____ 't. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe IVHardpan ❑ Previous Application Made: Yes ❑ N0 New Construction: Yes Ek No ❑ FHA/VA: Yes ❑ No ---TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 3 Septic Tank: Distance from nearest well----,� ---Distance fro fund ' n-- / M terial No. of compar+ments..___+� ____--Size___ _ _ -�_ a___Liquidl depth__�P_'' _-__Capacity.___rB_a-___ Dis oral Field: Distance from nearest well-___-2 _C7__Distance from foundat' C-c-��J_.Distance to nearest lot li ------------------- - ___� I Number of lines------___-- ✓'� Length of each line_____ ___ Widfh of trench____^_ -____.___~___ T` Type of filter mate Depth of filter material_______1__-_____Total length------1_ _t ------_--------- ! Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line________-_____ ❑ Number of pits----------------------Lining material-----_-----------------Size: Diameter-----------------------Dep+h--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------_-Lining material--------------------------__--___-___. Size: Diameter------ -----------------------------Depth------- - --------- - ------------ ----Liquid Capacity gals. Privy: Distance from nearest well ____'__________________________________---------Distance from nearest building------------------------------------------ 11 _____-_____----_ -_-________.___-.--___.❑ Distance to nearest lot line Remodeling and/or repairing (des cribe):--------------------------------r------------------------------------------------------------------------------------- --------------------------------------•---•-.----------------------•--------•----- ------------------------;--:-------------------------------------------------------------------------------•---------------------------- ------------------------------------------------------------------------------•----------•----------•---- ----------•--•----------•--------------- ---- ------------- ------------- -------------------------------- - ---•------------------------------------------------------------------------------------•------- ----------------------------------------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin Coun ordinances,—State law and rules and regulations of the San Joaquin Local Health District. i _ --- - (Signed)_ --------• -- .. r�� -- - --- -----------------------------------------------------------------------------------(Owner and/or Contractor). By:---- ----------------------------- ---- -- - ----- -------------------------------------------------------------------------(Title)-------------------------------------------------------------- (Plot plan, s wing size of lot, locati stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------ ------ ------------- DATE--------------------- REVIEWEDBY------------------------------------------------------------- ------- ---- -------- ---- ---- --------- -- DATE-----�- ___ _ - BUILDING PERMIT ISSUED--------------- A DATE------- ------ Alterations and/or recommendations---------=--------- ------- ----------- ------------------ ------- -------------------------------------------------------- -------------------------------------------------------------------- --------------------------------------------------------•--------------------------------------- r ------------------- -7 <24n- --------------------- - - •---•�----------------------•--------------------------------------- 77 FINAL INSPECTION BY:------ - -=------------ - •-- ------------- xDate. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfree4 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1=S-9-2M Revises 1.57 F.P.CO. r