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APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate) !/- -Rol A'.10Date Issued --- �_� 1 _ 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 AND LOCATION aZr �� .Ul. -----=--------------------------------------------------------------- ------ Owner's Name------------- --- • ?1-4- -�_ ---------------------------------------------------------------------------------------------- Phone------------------------------------ +. Address --- -- - ------------------------------------------------------------------------------- 1 Contractor's Name - ------------------------------------------------ --------------------- ------ Phone----------------------------------- Installation ------- ----- --- Installation will serve: Residence- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___�__ Number of bedrooms __a2' Number of baths __/__ Lot size ___ _________________ Water Supply: Public system Erc-ommunity system ❑ Private ❑ Depth to Water Table Z/4 ft_ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [j` New Construction: Yes ❑ No P4---FHA/VA; Yes ❑ No g4__ F� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sep 'c Tank: Distance from nearest well-_______________Distance from foundation--------------------Material------------------------- ---------------._______- No_ of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity---------------------- isp Field: Distance from nearest well__________________Distance from foundation________________-_-Distance to nearest lot line--_----___--_____ Number of lines________________r__-_ [J -= Length of each line-------------------.----------.Widfk of trench---------------------------------- Type of filter material_______________-______`Depth of filter material-----------------------Total length-------------------------------------_____ Seepage.Pit: Distance to nearest well__ 2 �_�pistance f om f ndation____ -___-_..Dis n.ce to nearest lot line---- 0� Number of pits-___J-__-_________Lining material_2r _--Size: Diameter__, --------- p Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material-------------------------------------- F-1 Size: Diameter--------------------------------------Depth-------------------------------------- -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well______________________________ _________________Distance from nearest bu;iding--------------------------------- Q ❑ Distance to nearest lot line-------- ------------------ ----------------------------------------------------------------- ------------------------- r f Remodeling and/or repairing (describe)--------------- --`�--------------- ---------- _ r - •- ••--------•--••-------------------------------------------------------------------- ------ -----------------------------------------------------------•-•---------------------------------------------------------------------------------------------------------------------------------------------------------------- i I hereby certify .that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules-and regulations of the San Joaquin Local Health District. y 4 (Signed) --------------------------------------------------------------------{D.btn Contractor) y By-------------------------------------------- -f- -------------(Title)------- - (Plot plan, showing size of lot, locatio system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y -- --------- --- - --------------------- ------=-----=_------------------------- DATE------------y--A. REVIEWEDBY------------------------------------ ---------------------------------------------------------------------- DATE-------- -I-----•••-------- BUILDI - NG PERMIT ISSUED - DATE -'_ - -- -- ---------------------- Alterations and/or recommendations:---------------------------------------------------------------------------------------------------------------------------- ---------------------------------- ---------------------------------•------------_-----••---------•---------------------------------------------------------------------------------------- •-•--------------------------•--------------- -----------------------•---•-• ---------------•------------•---------•---------------- -----------------•------------------------------------�-------------------------------------- ----------------------------- FINAL INSPECTION BY: _qA51�l f - Date ---------------------------------------------------------------------- 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 FRCO.