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APPLICATION FOR SANITATION PERMIT Permit No. ,ti f o ,k (Complete in Duplicate] Date Issued ___�V/ i • �;. I Applicat an 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, - f'� /! �•%p��t b - ------- -----------------------=------------------------------- JOB ADDRESS A D LOCATION.____CIA- _ _�___ , -/_�-----^--- � -- z Owners Name ---- = Phone_ 1 =_ ` Address: ------ - ---- -'----`- Contractor's Name__ . _...-..__,'b- ' ------ i C `�1 !/ r ---------------- Installation --------------Installation will serve- Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I___ Number of bedrooms __Number of baths I___ Lot size '_________--______________ Water Supply: Public system El Community system [I Private Depth to Water Table -------- ft. _ Character of sail to a depth of 3 feet: Sand Gravel ❑ µSandy Loam lay Loam ❑ Clay❑ •Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 2r 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.) c : 1 Distance from nearest well________________Distance from foundation---------------------Material---------------------------------------.--.____. A-*- - No. of compartments--------------- Size--------------------------------Liquid depth--------------------------Capacity---------------------- os iel�l: J Qistance from nearest well_ _ ____.._Distance from foundation___ __ 'r I ____.__.D stance to nearest lot line.-__�1__.___.-- �"�� Number of lines_______ _______ ___ �_. Length of each line___ sT..`..... ....... Width of #rench____�.' '�_..____._______ AAA Type of filter material__ �_ J _Depth of filter material----f_c _ _ ___ .____ ___Total length____________ O________________.-- Seepage Pit: Distance to nearest well----------------------Distance from foundation.......-------------Distance to nearest lot line____-__._____---- ❑ Number of pits----------------------Lining material--------- ------.Size: Diameter-------------- --------Depth-=------------------------------- Cesspool: Distance from nearest well____-_________-Distance from foundation___________________ Lining material-_______._._______------.-_________- ❑ Size: Diameter------------------ ------------------Depth-----------------'------------------ --------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building------____.___.___________--____..__-_-_. ❑ Distance to nearest lot fine-------- ----------=---='=------- ----------------------------=-------- ----------------------------------------------------------------- modeling and/or repairing (describe)--- ---- ---- -------- ------------------..._-- :-•-----------•-----•------- ' - ----- - -.fir�� 1 Re ----------------------------------------------------------------------- ---- -- - -- -----•--------•--------------------- ------------------ ------------- ----� --------------------------------------------------------=---------------------------------------------------------------------------------------------------------------------------•----------------- ----------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules and regulations of the San Joaquin Local Health District. (Signed)... ¢� �/ 1 ,_- __} f' / --------------------------------------- Contractor) B ------------------------------------------------------------------------------------ -----------=---------------------------- �- �,� � ---------(Title) (Plot plan, showing size of lot, location of system in relation we s, buildings, a c., can be placed on reverse side). F911, TME T USE ONLY APPLICATION ACCEPTED BY------- ----- ----- - ------- -------ii�----- DATE-- r --------------- REVIEWED ----------- REVIEWEDBY------------------------------------------ ---------------------------------------------------------------------------------- DATE------ -------------------- -----------------------••------ BUILDINGPERMIT ISSUED------------------------------------------------------ ------------------------------------==-------- DATE------------------------------------------------------------- Alterationsand/or recommendations:-----------------------------------------------------------------------------------------------------------------------------...-..------------------------•--- --------------------------•• ----------- •--------------------- -------------------------------------------------------------------- -------------------------------------------------------------------•---------- -----------------------------------------------------I——-----------------------------------------------------------------------------------------------'---------•-------•------------------------------------------ -------------------------------------- --------------------------- -------------------------------------------------- FINAL INSPECTION BY:.--------- ------ Date_...JF__ _ - � ---- 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 F.P CO.