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APPLICATION FOR SANITATION PERMIT Permit No. ` (Complete in Duplicate) y S Date Issued _--../•._2_ Aplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Th is• application is made in compliance with County Ordinance No. 549. o e--- JOS ADDRESS AND LOCATION ----- - ---------- ----•-••------- Owner's Name---,e.7.-�r(� !..- ... - ---------------------- Phone.--------------- --_------------- Address--- ------•-----------------------•----------------------......_..........- -----------.....••-- Contractor's Name.. ---------------------- .... - .--------------- Phone ! - Installation will serve: Residence O"�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:_. Number of bedrooms __ �.. ��--� / � Number of baths _____._. Lot size _-__ ......_. _ __________________ ,"Water Supply: Public system ge-c-ommunity system ❑ Private ❑ Depth to Wafter Table !l%. ft. :Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [-Hardpan ❑ Previous Application Made: Yes ❑ No P-*'� New Construction: Yes ❑ No ©/FHA/VA: Yes ❑ No [ate' TYPE 'OF INSTALLATION AND SPEC IFICATION5„. r (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) e ic�T Distance from nearest well_________________ Distance from foundation -------------------- Material ------------------------------------------------- No. of compartments--------------- ------Size ----------------------- ----:--- Liquid depth--------- __._---..-_. Capacity -------------.-..------ pp Fie Distance from nearest well. Distance from foundation... ...... Distance to nearest lot line.__.. Number of lines -------------------------------------- Length of each line --------------.-----_-------.Width of trench ----------- --- -- --------- Type of filfer material_-- __ ..............Depth of filter material_,. ........... ...._--- Total length ------------------ .___-___________________ I i Seepage Pit: Distance to nearest well f Q.D. .......Distant om f7�}undation__/�... .-------- Distance to nearest I line. -/.6 ......... Number of its______ Linin material. %`_ -?-.-Size: Diameter_._4J_3.---- Depth.__�s�.....•............... r 1� P........ 9 Cesspool: Distance from nearest well.................Distance from foundation -------------------- Lining material._______.....______............_..___. t ❑ Size: Diameter. = ------ -----------.....-...Depth ----- •-••-------- -•------•---_Liquid Capacity... ......................... gals. Privy:. Disfiance from nearest well ------------------------------------------------- Distance from nearest building _______._-_•_----..--_.---..__-._.-_---.-. ❑ Distance to nearest lot line.:,.--. .:..........._ ......-----------•---•-------- .-----------...........------------...--•-•------•----.........--•---............._.. Remodelingand/or repairing (describe)------- ------------ ....---------- --------- ------------------------------------------------ ------- -.......................................................... ---------------------------------------------------------- I......... ------------------------------- ............ -----------------------------.-__.----------•--..--•--•----------------------------•-----------•---------•-----------------------------•-----------. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e aws, and r es and gulations of +he San Joaquin Local Health District. S' ed ` ____._..... ner and/or Contractor) I ( )- - ------------- ~ By: ------------------------•---•�-��------- ��- L --- ----- l =-------(Ti+le)------- t ----------•-------- S (Plot plan, showing size of lot, location of system in relation to +oGelis, buildings, etc., can be placed on reverse side). S FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----- ........-------------------••------------ •--•--...__....... DATE----- ................................................. REVIEWED BY------------------•- ---------------=------------------- G. -------------------------------------------------__ DATE... .. BUILDING PERMIT ISSUED ----- .......... ........... �`S DATE---------- Alterations and/or recommendations: ........ .---- --- --------------------------------------------------------------------..... --------------------- ----- -_.... .._ -----.....................:......•-•---•-••-----•-••--.-- .................... --...-•------•------------------------------------••�...----.�---.--.•.__ - ..-----------------......-- --.-•-•----------------......---......................................................... •-•--------- ------ FINAL INSPECTION BY:__._.Lrr------------------------------------ Date_ ............................ � ' t SAN JOAQUIN LOCAL HEALTH DISTRICT j 130 South American Street 300 West Oak Street 132 iSycamore Street 814 North "C” Street 1 Stockton, California Lodi, California Mf0feca, California Tracy, California ES -9-2M Revises 1-57 F.P.CO.