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' APPLICATION FOR SANITATION PERMIT Permit No. _.__. (Complete in Duplicate) ` Date Issued - -o --- Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. , .. JOB ADDRESS AI -------- ------- -------------------- -- ' - f - - ---Y= ------- --------------•--- one ---� SPh OwnersName---- -_------------- ----------------------------------------- Address -------------------------•--• -,-------- " , ------------------------- ---- Address---.......... ,{ ------------------------•---------------------- -----------------------•------------------------------- Contractor's ------------:-.------------Contractor's Name---,_-04 - ---------------------------------------------rt------------=------------------------ --,---- ---------------- Phone------------- ---------•---------.. Installation will serve: Residence - Apartment House ❑ Commercial ❑ Tra r Court ❑ Motel ther ❑ A lQ ------------------ Nurribar of living units: _Number of bedrooms ---7- Number of baths .-___._ Lot size ________: ____. r Water Supply: Public system ❑ Community system ❑ Private)'Depth to Water Table _-eft. 1 Character of soil to a depth of 3 feet: Sand []. Gravel ❑ SandyLoam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes �o ❑ 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.) Y y p undation---=----------------Material-------------------------- No. ----•-- -------------- Septic Tank: No Distance com artmen s- well--------------- -D'eance fromfoundation --------Liquid depth---------------------------Capacity..------------,---•---• 1 Disposal eld: Distance from nearest well----T -.-.-Distance from foundation__ __ �-----_.-.Distance to nearestt lin �e�-_____---_ - Length of each line----- -----------.width of trench--____-- --------------------- Number.of lines----- _!_--__. 4 Type or filter mater;lal___ __.U��_.___Depth of filter materlaL__.�_��J_"".--Total length___� _----------------------- N Seepage Pit: Distance to nearest well _____________- __.Distance from foundation_______.____...____.Distance to nearest lotine-_.-___.___.__.._ Number of pits �------------------Lining material---------- -----------.Size: Diameter-----------------------Depth------ ----------------- ---- \ Cesspool: Distance from nearest well________________Distance from foundation--- material------------------------------ __- ❑ Size: Diameter_,,---------------------- ---------=Depth--.--------------------------------------------------Liquid Capacity..... gals. Privy: Distance from nearest well------------------------------------.-------------Distance from nearest building------------------------------------------ ❑ Distance-to nearest lot line--------------------------=--;---------------------------------------- ------------------------------------------------------------------- Remodeling and/or repairing (describe]:_----------------------------------------------- -'t' " ------- - '-`� _� --- -- -------------- -------------- --- ,. :. .- -- --- ------ --- -- - ------- P I hereby certify•that I have re p pp _ -ared this a lication and that the work will be done in accordance with San Joaquin uin County ordinances, State laws, and rules an egulati --------------------------------ons of the San Joaquin Local Health District. ,. - (Owner and/or Contractor) Signed {O d _-----------------_-------- --------------------(Title)_- -------------------------------------- ! (Plot plan, showing size of lot, location of systerri in relation to wells, buildings. etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I 1 APPLICATION ACCEPTED BY----- ---------- ------------- ------------- �------------------- ------------------- DATE ' REVIEWEDBY------------ = ------------------ -- --------------------------------:=------ DATE------- --- ---- BUILDING PERMIT ISSUED------------------ ---- - DATE..--. "--_-- ------ - ---- --------------------------- �r�----- ------------------------------I---------------------------- Alterations and/or recommendations:_--_- _ r is ------------------ --------- ---=----- - --------------------- ' -------------------------------------------------------- - i ------------------------------------ 4 , - - - ----------------------------- F��[�////1�J\J�� Date- --- -------- --------- FINAL INSPECTION BY:-------- -- -�.�--�--------{)//- - - --------- k SAN JOAQUIN LOCAL HEALTH DISTRICT _ 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Streefi Stockton, California Lodi, California Manteca, California Tracy, California ". ES--9-2M , Revisep; 1•57 FRCO.