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APPLICATION FOR SANITATION PERMIT Permit No. _/Q..4.......-.... (Complete in Duplicate) 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. JOB ADDRESS AND LOCATION.- -------�._�------ /�1 ---- ��----•_..._._. - - Owner's Name-------- c /Y Phone. Address_.-------- ��s�.-------� ��_ 1 ''_. _ Contractor's Name-------- _ tJ ,� Phone- . --- Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _*r.____ Number of bedrooms . ""-- Number of baths _"___ Lot size ___,____ -----------------------------------------_____ 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 ❑ Clay ❑ Adobe,' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No. FHA/VA: Yes [-] No TYPE OF INSTALLATION AND SPECIFITIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ��Sep Distance from nearest well______________Distance from foundation--------------------Material_________._.___.__..___________.___.___.._____... � No. of compartments----------------------- --Size-------------------------------Liquid depth--------------------------Capacity--------------- Disp dif d: Distance from nearest well---- _Distance from foundation--------------------Distance to nearest lot kne__ a Number of lines__________________________________Length of each line------------------------------Width of trench----------------------------------- V) Type of filter material_______________ _____ __Depth of filter material-----------------------Total length------------ S a � le to n#crest well -Distance Aom foundation J.___.Disp'nce to nearest lot� rNumberof P ateral_ QGSize: Diame er 'n- ---- -- De th101 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------------------------------------------ El Distance to nearest lot line--------------------------- ------------- ------------------------------------ •------------------------- 9 Remodeling and/or repairing (describe):_ � s.= rte___________ ../_.-, ":' --------- � ..� . { - ---------------------------------------------------------------------------------------------- ------ --- ---- ------ -------------------- ---------------------------•-----------------------------------------------•--•--------------------------------------------------------------•---------------------------------------------------------------•----•----------- 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, a r les andmgu{ationelan Joaquin Local Health District. ___________s�!(Signed) �__________ ----- /� w ------Owner dor Contractor) B , _ .` c� -(Title)--------- --- (Plot plan, showing size of lot, location of system in relation to wells, bui gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------- -- --S ---------------------------------------------------- DATE------------------------------------ BY---------------------------------------- ---------------------------------------------------- DATE- ----------:--------- --/---.:1------------------ BUILDING PERMIT ISSUED-.-------------- - - --- ------ DATE.--------- r---------------------------•--•-- Alterations and/or r_ecommendations/: -------------------------- ---------------------------------------•------------ --------------------------•--------....------- ________ NY4�-_______�____ _-t__v.4___.____________ __________________________._____... ..... .--_______t-- _______________ '"y___-__ k__ ----------------------------------------- r -... 115 --f— �t ------------------- ----------- r ----•---------- ----------------- ------------------------------------------------------------ ------------------------------------------------------------------ -------•------------------------------------------ ------------------------------ ------------- ----------------------- - "-- `---------------------------•-----------•--------------------------------------------------•-------------------------------•------..-- . _ I �' - -- FINAL INSPECTION BY-------------- -= ,' ' ' 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 ES-4-•••2M Revised 1.$7 F.P.CO.