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APPLICATION FOR SANITATION PERMIT Permit No. -IN (Complete in Duplicate) Date Issued _ IL d Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the worldherein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------------- ------------------------- ----------------------------------- Owner's Name------------=!t----=--=yJ�7tr_- = 7 �'"-------------------------- ------ ------------------------------------ Phone-------------- --------------------- Address---------------------5" Contractor's Name--------------- _n Phon 5- 7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: __ _ Number of bedrooms __.Z_ Number of baths ___-Z Lot size ___ __'______,J -___._ Water Supply: Public`system Community system ❑ Private ❑ Depth to Water Table _____:__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] ClayX Adobe E] Hardpan F]Previous Application Made: Yes [:] No ® New Construction: Yes M No E] FHA/VA: Yes ❑ No ❑ dT' P F STALLATION AND SPECIFICATIONS: o tic tank or'cesspool permitted if public sewer is available within 200 feet.) } Distance from nearest5--rf___ Distance from foundation._Z__�_____.__.Material__________L_�__ __ No. of compartments--_--_�------ --------Size--- - �� ---5--------Liquid depth--------�Z--------------- ®------ I ield: Distance from nearest well-_-__S._ Distance from foundation____ems____-.__.Distance to nearest lot line--- �* Number of lines------�------------------------Length of each line________.?'- ------------.Width of trench----------Z_- --------------- --- -- Type of filter material_______,lC�a�_$4 Depth of-filter material------Z_Y-_______Total length--------��_________________________ Seepage Pit: Distance to nearest I ell_____S ------Distance from foundation____,�J ___.Disfance to Dnearest _ lot�lin/e�-_/_1 -___ '- Number of pits------- material-------fQ_--_Size: Diameter-------?��_______. Cesspool: � Distance from nearest well_________________Distance from foundation-_-._-_____________ Lining material_____--_...________-________._____ �! ❑ Size: Diameter------------------------- ------------De th--------------------- -------- ---------------------Li uid Ca acit Y-------------- ----------gals. Privy: Distance from nearest well ___________-------------------------------------Distance from nearest building_________________--__________--___._____- ❑ Dist ante to nearest lot line----------------------------- r Remodeling and/or rep Mg (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, State laws, and rules and regulations of the San Joaquin Local Health District. G' 'R r L�— (Signed)----------------------- - ------------------------------------------------(Owner and/or ontracfor) �Y� � ------- --------------------------- Title----------- - { ) -=-------------------------- (Plot plan, showing size of lot, Ioca�- --ftein relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - ------------- --- DATE REVIEWED BY ------ ---- ----- - - ---�-------------------------------- ----- DATE---- r -------/-------------------------------- BUILDING PERMIT ISSUED___.-_________________ -- -- --------------------------------------------------------------------- DATE-------------- - --------------------- ------------------ Alterations and/or recommendations:------------ ---------------------------------------•-•-------------------------------------------•----- ----------------------------------------------------•----------------------------------------------------------------------------------------------------------------I-------------------------------------------------------- --------------------------------------------------------1;01-�1-1--------------------------------------------------------------------- -------------------------------------------------------------------------- -----•-------------------- ---------------------------•--- --------f------------------------------------------------------------------------------------------- ---------- -------------------------------------------------- -- -------------------------------------------------•------------ ---------- FINAL INSPECTION BY------------ --- - --•-------------------------- Date .+/ 1 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-9-2M Revised 1.57 FRCO. 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