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APPLICATION FOR SANITATION PERMIT Permit No. -_...1 ;�U... -- (Complete in Duplicate) �/ This Permit Expires l Year From Date Issued Date Issued .____ -..--__S_ 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 Ordinan o. 549. f JOB ADDRESS AND TION------- -- - '� `------------- -- ------- Phone----- -------------------------•---- Owner's Name------ ---- •-- - ----••-------- -=------ -- -------- - - - - - ---------------� Address---------------- Contractor's Name---------- .---- -- ------ - - - - ------- 7-----. -m - ------. r._. Phone__ �_. Cr.�-(�/ Installation will serve: Residenc A rtment House ❑ Commercials Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths _______ Lot size _-- -- -•__�� -----________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 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 SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �ptic , a Distance from nearest well_________________Distance from foundation-------------------Material------------------------------------------------- j'g r No. of compartments--------------------------Size------------------------ -------Liquid depth-------------- ----------Capacity----------------------- Disp'osai r : Distance from nearest well_________________Distance from foundation-------------------.Distance to nearest lot line___________-_-_. �0 �fL Number of lines-----------------------------------Length of each line-------------------------- -Width of trench---------------------------------.-- `'� Type of filter material-------------------------Depth of filter material-------------------:__Total length-------------------------______S Distance to nearest 11 _Distance foundation---461-----. stancpfo neareslot line� ._.__.___Lining material_-__Number of pits_____ _ * ize: Diameter--------- r__._.___Depth_ �3_ _______y_____________ C material rw, Distance from nearest well from foundation...._.___._._______.Lining material-_-_____---.______-._____________---_. ❑ Size: Diameter--------------------------------------Depth--------------------- •----------------------------Liquid Capacity----------------------------gals. T\ Privy: Distance from nearest well-------------_-----------------------------------Distance from nearest building.________..______--__-_--_______-____.___. ❑ Distance to nearest lot line------------------------------------------------------------------------ ------------------------------------------------ ------ Remodeling and/or repairing (clescrib ------- - ------ ---------- ----------------'— -------------------------------•--- --- ---------------------------------------------------------------------------------------------------------------------------------------------------- ------------ I hereby certify that I have pre red this plication and that the work will be done in accordance with San Joaquin County ordinances, State lawd es d regulat' s of the San Joaquin Local He . District. - ��/or�C�onfr�acfor) (Signed)----------- --- -- --- -- --- ---- -- By---By:---------------------------------------------- -------------------------------------•----._ - ----- ------ - -----{Title ---..... (Plot plan, showing size of lot, location of s in relation to wells, bu' s, etc., can be placed on reverse side). FOR,DEPARTMENT96E ONLY APPLICATION ACCEPTED BY----------- - - -- ------ ----------------- -------------------- DATE---------��----- ------------------ REVIEWEDBY-------------------------------------------- ---- ---------------------------------•---------------------------------------- DATE---------------------------------------------------•------- BUILDINGPERMIT ISSUED-----------------------------------------------------------------------••---------------------------- DATE---------------------------------------------------------.-_. Alterationsand/or recommendations------------------- ------- ------- --------------------------------- ---- ------------------------------------------------•-••---------------------------- W- C-9--j - __ -----_________ _ f _-__-___. _ _ _ __ ______________._..__-__-_-.-__ FINAL INSPECTION BY:-_ __ ... ___ ___ .. -- Date----- - -- S/�o------ - - -- ------------------------- 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 V59 F.F.Co.