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APPLICATION FOR SANITATION PERMIT Permit No. .__. ---- } r (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. S49. JOB ADDRESS AND LOCATION:__-& _ -- = -----'- ------ Owner's Name------------------------ ----------------------------------------- ------- - Phoned �� Address ------- -----------•-------------------------------------------•-------------••--------------------------------------•------ -------------•----------•------------ , N —�,— Phone 9 Contractor's Name-------------•-------•---•- •-moi- - ----a'------------------------------------ •- ---------------- ------- --------- installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1---- Number of bedrooms __YNumber of baths ---L Lot size _____ ---- -�--- ----------------------------- Water ---------------------- Water Supply: Public system JR_Community system ❑ Private ❑ Depth to Water Table �70ft- Character of •soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam R❑ Clay El Adobe ff.- Hardpan 11Previous Application Made: Yes ❑ No F1 New Construction: Yes ❑ No ❑�,r��a ` /t- '- . TYPE OF INSTALLATION AND SPECIFICATIONS: 111 (No septic tank or cesspool permitted if public sewer is available within 200 feet.)_T I icjaIn Distance from nearest well-----------------Distance from foundation _.____.____.____._.Material.._._--_____________.__________-_._...._.._____. [<< f----I No. of compartments--------------- ----------Size---------------- - Liquid'depth--------------------------Capacity----------------------- W is osal fields Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line----------------- w I-^I Number of lines----•---------------- ------==-----Length of each line------------------- Width of trench. [f� Type of filter material-------------------------Depth of filter material------------ -----------Total length----._-_-__-----_---_-..---_--.-----.__.__ r Seeps e Pit. Distance to nearest well- __._Distance fr��mU. � f11oundation QS_____..___.Distance to nearest lot line.--____ Number of pits____.__-_- Lining material ! -----.Size: Diameter__. {.----Depth_.c �_____ __________ _____ Cesspool: Distance fi-om.nearest well-----------------Dislance from foundation-------.............Lining material--._______-_--____._____------- -- ❑ Size: Diameter----------------- -- -------------- -Depth---------------------------------------------------Liquid Capacity-- -------- -------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building----.------------------------------------- ❑ ---------------------- Distance to nearest of fine___.___________________________________ __ - -- ------------------------- ------------------------------- Remodeling and/or repairing (d.e`scribe)----------------------------------------------------------------------------•------------------- ------- ------------------------- --------•-------•---- [ -- %------------------------ ---------------------•------------------------------- ! --------------------------•-•----° ----------------------- ----------------------------- ---------------------------------- ------------------------------------------------------------------------------ ------------------------- --------------------------------------------------------------•-------------- I hereb if that I have'pre ed this application and that the work will be done in accordance with San Joaquin County ordinances, State I ws, and rules an' regulations of the San Joaquin Local Health District. n r Contractor) (Signed)------ = ------ -•-- ( � 7 F �� . �1 (Title) .o _ <_l_r^? i� : ------------- gY:----•--------------•--------------- nSw e (Plot plan, showing size of lot, location of system in rel tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- r ----------- ------------------ DATE ' REVIEWED BY------------------------------------------- -- ---------- ------------ -------------------------------------------------------- DATE------------------------------------------ ----------------- BUILDINGPERMIT ISSUED------------------------------------- ------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:---------------------- ------------------------------ ---------------- ------ 4 ------------------------------------------------------------------••------------------•"- ------------------------------•-- - FINAL INSPECTION BY:--------- r ------ Date--- U `"' �`- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1 sycamore Street 814 North "C" Street � 130 South American Street '` 300 West Oak Street 132 5 Y Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M 10-52 Revised W-2100