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APPLICATION FOR SANITATION PERMIT Permit No. --------------:'_._-' jX �J"T (Complete in Duplicate) Dane Issued . ----------- Application is hereby y m ade 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. . l ----JOB ADDRESS AND LOCATIONr(- .._ ------------------------------------ .: - ` ---- - Owner s Name--------- 3,�-kE- - - ------------------------- - ------ ---------------- one----- ----_-------------------- Address �A _ _... __-------- ---------------- ------------------------------------------------------------------------------------------ --------------------- Contractor's ;,lame.--- - s-' --- ----------- . ----------------------- Phone Installation will serve: Residence Apartment House Commercial � � ❑ p ❑ ❑ Trailer Court ❑ Motel ❑ Other Number of living units: -/-_ Number of bedrooms ---/.. Number of baths /- -- Lot size L2.f_.._ ----------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel L] Sandy Loam E] Clay Loam ❑ Clay E] Adobe M-_"`Hardpan p Previous Application Made: Yes E] NoNew Construction: Yes �o ❑ FHA/VA: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f Septic ,l// nk: Distance from nearest well (l 4___Distance from foundation / _ -------Material No. of compartments.. - ----------SizeLiquid depth !. Capacity-- �X/� . --_ f•' 1 ._ r l �.�-..Distance to nearest I�t Lin/eeK _�___-- Dispcsak ..ield: Distance from nearest we!I �✓.;_ �___Distance from foundation_:-/ _F -- -- Number of lines_- �.------------ ------------Length of each line_- -- --2.__,-.-.---Width of french- -- of filter material-------11k_ --Depth of filter material-------- -° Total length-.--- .................... Seepage Pit: Distance to nearest well------ ---- _-----Distance from foundation--------------------Distance to nearest lot lire--- U Number of pits------ --Lining material----------------- --- -Size: Diameter---------------_ Depth----------. -- ------------------ Cesspool: Distance from nearest well-------- -_---Distance from foundation _--...Lining material-------. ------------------- Size. Diameter----- ------ --- ----- --------Depth_ -- ------------ ---------- -------------- ----Liquid Capacity- ------------ ---- gats. Privy: Distance from nearest well----- ---- ---------------- --------------Distance from nearest building-------------------------------------.---. ❑ Distance to nearest lot lire_____ ---------- Remodeling and/or repairing (describe)--------------------- -- --------------------------------------------------------------------------------------------- -------------------- --------- ------------- --- p p Ap .----- --- ------ y I herebycertifythat I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. X(Signed)---.-..L�. 4 _ _--- L�'�C�J2�� 1 � --------------_-.-(Owner and/or Contractor) $y=-------------------------------------- ------------------- --- (Title) -- -- ------------------- ------------------- - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--- --- --- ------------ - ' -- ----------------------------------- DATE--------------------------------- REVIEWED BY - ----- --- DATE---- BUILDING PERMIT ISSUED---- r a ------------- - BUILDING DATE_.._• r f ` -------------- Alterations and/or recommendations:_______.-__-_ _ _ ____ .,..`----- - __ ----- ---- ----- --- _ -------------- ------ ----------------- - --- -------------------------- --------------------- �? „ FINAL INSPECTION 5�- BY:. - ------- - 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 FS-9-211 . Revisec 1-57 F P CO.