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APPLICATION FOR SANITATION PERMIT Permit No. ................. (Complete in Duplicate) 3 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• -3t,2 'XL��2. k JOB ADDRESS AND e �1-r �-----------D -+ --------------•------- Owner's Name--------------------------------- ---- --_— N,----------- ----------------------------------------- ------ Phone ---el--7 AddressQ Q_ = ----------- ------------------- ------------ --------------------- Contractor's Name----------------------------- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living.units: :_ -_:__ Number of bedrooms 4-lrTmber of baths __/___ Lot size _____________ —_________.____ Water Supply: Public system ❑ ' Community system ❑ .Privatej', Depth to Water Tabler�t i? Character of soil to a depth of 3 feet: . Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan f - Previous Application Made: Yes fi4 No ❑ New Construction: Yes J4 No ❑ FHA/VA: Yes ❑ No K TYPE OF INSTALLATION AND 'SPECIFICATIONS: ' G r (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_4��--------Distance frofoun _ ationd_ _ _ __ .Mat ria)-____________________________-___ .__ --, No. of compartments_____ _ r_,___________Size___ r _____ _____Liquid depfh_____ -.___.____capacity,__.__ __p._- Disposal Field: Distance from nearest well. Distance from foundation------Z6__!_-_Distance to nearest lot line_-___��~__.. W Number of lines_-_--- Length of each line----------- OWidth of french------------ _ _!!_______ _ Type of filter material_ _____ _________Depth of filter materia!--------� _'_____-_Total length_________,-- ? ------ Seepage Pit: DistanceJo nearest well------------------------ from foundation------K------------Distance_to nearest lot line---_.-_---._-.-_ ❑ Number-.of pits----------------------Lining material----------------------.Size: Diameter-----------------------,Dept h--------------------------:...... Cesspool: Distance from.nearest"well"------------k.'_Distance from foundation-------------------.Lining material-------------------------------------- El Size: Diameter---------- ---- Depth-------- - � �. ---------- Li Liquid Capacity ----------gals. *- " ' ' .-Distance from nearest building Distance to nearest lot line--------- t T � - ` ' ` -- �; F _ Privy: Distance from �earest well = - - - ---------------------- ---------------- Remodeling and/or repairing (describe) ----- -`==------------------ •�`""� `---•--- •----•-- -A------------------------------------- --- ----------------- ------------•-•----------------•-----••-------•- -----------------= ------ = - = --------------------------------- --------------------------------- ------_------------------ ----------------_._..........• ------- --------------- ------------------------------------------------------------------------------•--------------- --•----•-------------------------------_..._.,..--------------------------------.. . y., � % X,0- ---------------------------------------------------------- I •---- ----- ----- 1 hereby certify that:) have prepared this-application and that the work will Abe done in accordance with San-Joaquin County ordinances, State laws, and rules and regulations,of the San Joaquin Local HealtWDistrict. (Signed) '- - C#' ' '- ,�-�-- Y - - ------------------ --------- -----(Ow_(Owner and/or Contractor) s k .-- __ -f- { ------ -- ------- A - ; _ (Title) _ (Plot plan, showing size of lot, location of.'system in relation to'wells, buildings, etc.., can be placed on reverse side). i FOR DEPARTMENT USE ONLY.' APPLICATION ACCEPTED BY -------------------- DATE --------------- -- ----= r - a r _____ __ J DATE - .. --� --�- ---•----•--------- REVIEWED BY ----------------=--------- ------------ - - --- _ )I- BUILDING PERMIT ISSUED------------------- ----------------------------------------------------------- DATE----------'_---------—---------------=---------------------- Alterations and/or recommendations: - =--------•--------------------------------- r ----------- - - -------.... -------------------------------------------------------------------el!------------------------ ------ FINAL INSPECTION BY:: r 1 s _ '__:__ - - Date.... --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r? 130 south American Sfreet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P,CO. f/