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n Irl Iti a Permit No. APPLICATION FOR SANITATION PERMIT -- -�------- a (Complete in Duplicate) Date Issued - _____ _� t � v 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..._- > _ `---=-----•� -�'r�---------- ,�r Owner's Name------ -------------------- ---------------- ---------- PhonL_ _ -}` Address- 73--------- - ------ � ` ' Contractor's Name--- - " -_ PhoneSC✓�-'. Installation will serve: Residence I Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ___ Number of bedrooms -„�. Number of baths .__�__ Lot sin ------�r�' ?________________________________ Water Supply: Public system Community system .❑ Private ❑ Depth toWaferTable ________ ft• . Character of soil.to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ CIa;Co'm ❑ Clay ❑ Adobe, ' Hardpan ❑ Previous Application Made: Yes ❑ 'No New Construction: Yes ❑ NoFHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) w ,. � .. ._. - q P of compartments..- Size-------------------------------- No. Li uid de th - epic Distance from nearest well________________ Distance from foundation___-.____________ _.Material--- Capacity________________._____ Field: Distance from nearest well________________Distance_ from foundation__-----------------:Distance to nearest lot line___-_______-____. Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of fi{ter material-------------------------Depth of filter materia!-------------------f_Total length-______.__________._________-__---- ____ Seepage Pit: Distance,to nearest well___Distance fr fo ndafion___--a..__:'Distance,to nearest lo�neff-------- .4 _______ Number of pits---:----/------------Lining material--- ---Size: Dia meter---: ---------- _-- tS-----=----------- Cesspool: Distance from nearest well-----------------Distance from foundation.---------.---------Lining material----------------------------------- __ Size: Diameter--- ------------------------------- Depth-----------------:----------------------------------Liquid Capacity---------------------------gals. Privy: �s �� Distance from nearest well_________________________________r.---------------Distance from nearest building----------.- (a ❑ Vs-L Distance to nearest lot line - --------- ----- - - Remodeling and/or repairing (describe}:------ --------- / {'�fG�----- e�-----------•-------- _-- ----------•z -' 1- -•------ -------- -- ------ ----- - - ------------------ -- --•------ ------•-----------------------•-------------•-•------------------------------•------------------------------------------------- -------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, 5011rules and regulations of fhe San Joaquin Local Health District. • - � Ownerand/or Contractor(Signed) - --- -----�- -- --- By=---------------- j ~ -- ----------- ----- ---------••(Title)------- --- -- -------------- (Plot plan, showing sizesize o location of system i elation +a wells, buildings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- -------------=-------- DATE .- ---------------------- REVIEWED BY---------------•-------------------------- - ----------------------------------=------------------------ DATE_ -------------- ---------------- ------------------- PERMITISSUED-----_--------------- --- --------- ----------------------------------------------------------- DATE---- --------------I----------------------------- Alterations and/or recommendations=-------------------------.----------------------------------------------------------- /0=�� S-.S' _� _._� ?.7f ------��a .S<J1P�7a-------- �-- ------ T i!ft - --------------------------------------------------------------------------- •------------------------- "S r�. --------------------- ----------------------------------- ---------- ------------------------------- ---------------------- --------------------------------------------------------------------------- ---------- - ---------------------------- BY.: ------------- FINAL INSPECTION BY.:........_ .. P � r4.: = Date------- " SAN JOAQUIN LOCAL HEALTH DISTRICT 130 SouthAmerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 9 Lc ES-9-2M , Revised 1-57 F.P.CO.