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\ a Ile APPLICATIQN FOR SANITATION PERMIT Permit No. �'e 1- (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 ANDTION- --_- -- :. a Y • ' --------------------- --------�'+ • .t Owner's Name----_- -- .. z. -..,.. ,. . �. - --------- --- Phone == ----�-- - '----- Y r Address---------- --- �� -�:-------:-------- -------------------------------- Contractor's Name ----•------- ' . �g ,k --- -- ------ 1F _ --- --------- Phone (®J�l 1. __�..F--�� Installation will serve: : Residence Apartment House [❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Nu#ber of k edrooms ,Number of baths _ L f size ..__ -5 -------- Water Supply:. Public system . Community system ❑ Private ❑ Depth to Water Table ff. ` r Character of soil to a depth of 3 feet: Sand ❑ Grav l ❑ Sandy Loam ❑ Ci y Loam ❑ Clay ❑ Adobe }Hardpan Previous Application Made: Yes ❑ o Er New Construction; Yes ❑+ No } Fl-1A/VA: Yest❑ No ❑ y TYPE OF INSTALLATION AND SPECIFICATIONS:' (No septic tank or'cesspool permitted if public sewer is available within 200feet.) t �. tic. ank:" Distance from nearest well-----------------Distance from foundation.,_-:---_.----------�Material No. of compartments-----------=----------: =Size------------------- �----- ---Liquid depth j :Capacity A - _ Disposal F d: Distance from nearest well _--. Distance from foundation -_- ---------Distance-to-nearest lot line____ Number of l;n`es---_V--------- _. Length of each line------ Widtli of,trench.--_ H Type of filter maternal'- - -;Bt'_ --Depth'of"filter material--_---f --_- ---Totallength -"- "�---' -__------ - Seepage Pit: Distance to nearest-well XZ_/"':DistancAIM— f r� } o nearest lot line------- -.r -g --__ _.Size: Diameter:-_ - �_ Number of pits:---- -;-- -__._--Linin material- __- --___.De th---_-. ____________ T Cesspool: Distance .from ealest we l---_ -----_ -_-Distance from foundation f___ �4 ;Linin �aterial----. - p -- g ' ❑ S¢e#Diameter---- ��--------------- ---------------Depth---------- ------ [ rl'U uid tCa acit --------------gals. ----------------------------- - Privy: Distance from nearest well------- ------_---_____--.-__-_ -__ __Distance, from nearest buildin � -, = istance nearest o ine - ------ ,--------- -----------------------------------------' Remodeling and/or repairing (describe):___:--_________ ____ _ ________ __ ----------------------------------- #- ---- _ -- -------- --------•------------- ---- f ------------------•----------------___ - , ------------------ ordinance5b5tcer h wthat Idhave a d regulations"of theSan Jo uin Local Health l Y certify pared this a' `lication and that the work will be done in accordance with San Joaquin County t District. (Si ned ! " `s 9 )__----- --------- ---t - -- ---- , --------- caner and/or Contractor) By:------------------- --- -------------•------•-----------=----------(Title)----- ------•--------- ---------------- (Plot plan, showing size of lot, location of sys 1 relation to wells, buildings,-etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY If APPLICATION ACCEPTED-BY--------- ------------------------ -= ------------ DATE- ------------•---•----- REVIEWED BY------------- € -- ----*��'------- #. ------------------ ------------------- ---�------------ --- --- ------ -------_---=------ ------ DATE----; -------- --- -=�--------•----------------------- B'JILDING PERMIT ISSUED--------------------r ------- DATE-- f v r Alterations and/or recommendations:--- __-_--_--- -- _ ;r %1' ------------ 1 - --------•-------- --------------------- -- -----••------- --------------------------------•-------•------•-------------•-----•----••------•- ------ — --------------------- -------------------------------- -------------------------- --------- -------- FINAL INSPECTION BY:.-- • �" �. " �S r-- -- Date _ --- SAN JOAQUIN LOCA HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California ,r Lodi,,California Manteca, California Tracy, California `5-4-2 Ail . Revised 1-57 F.P.CO.