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APPLICATION FOR SANITATION PERMIT Permit N � L (Complete in Duplicate) l 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. I p y, �, - JOB ADDRESS AND t CATION:-- f / - T ---------------•--------------------- ----------------------------------•----------- Owner's ----------Owner s Name--------- ---------------- -------- Phone---------- -------------------------- Address._..- ----------Address._..._ -Z4----- Contractor's Name----=------- --`------ - ------ - �------- -- -- ----------------------------------- Phone--•-•----------------•------------ Installation will server Residence W—partment House E] Commercial ❑ Trailer Court E] Motel E] Other [I,1 or- Number of living units: -Z--- Number of bedrooms'.!;.?__ 1\16mbei•'of baths Ae__ Lot.size __' �-- -__ �Z- _________________-____ Water Supply: Public system Community system'❑ Private'❑ `Depth to'Water�Table ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ElClay Loam ❑ Clay ElAdobe Hardpan [3 Previous Application Made: Yes ❑ No .P-O*'New Construction Yes Erl�o ❑ FHA/VA: Yes [?'No ❑ ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted`if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___—_____Distance from founciation__-_/*!9'._.----.Mate.rial---[!'td-- -. -- !______ ____________ No. of compartments____s�;__-.----------Site-�f.11 -+ -'#- ---�•tiquid"depth_-- -------------Capacity--- ------- No. oal f Distance from near st well__ '`------Distance from foundation___ _-___-_.Distance to nearest lot line____ ._____ Number of lines_} ____________ /Length of each line___.XP--- Width of trench Type of filter material ._ Depth of filter material--- --____Total length-____ 1 __..__________________ 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------------------- material--------------------------------------- ►1\ 1771 Size: Diameter = = Depth --------:------------------------------------------Liquid Capacity-_------------------------gals. Privy: Distance fromnearest well_---------------------------------------------------Distance from nearest building------------------------------.----_-__--- ❑ Distance to nearest lot line- - ----- ----------------- ------------------------------•-------------------- --------------- Remodeling or repairing (del ' g and>I P (describe:------------ -- -- -=------s�"_�`------ -- ----- - --- ---•---- - - --------------- ---------- - ----------•----------•---•---- ;---- ------#-----------=-------------------- -------------------------------------------------------------- --------------------------------------------------------------------=----------•-------------------------------.-.------------•----------- ----- 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 regula ions of the San Joaquin Local r ealth District. (Signed)------------------- -- -- ----- - �' --------L,.? ------ ------ - -----------� Contractor ------------ By:----------------------------- • --- - ------------------------------------- -•-------------------(Title) (Plot plan, showing size o t, location of system in relation to wells;-buildings,c etc.,can be placed on reversede). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------.:....- --- ------------- ---------------------------------- DATE--J--�----•-•------------------•---------------------- REVIEWEDBY-------------:----------- ----------- ----------- -------- ------------------------.------------------------- -- --- DATE-- BUILDING PERMIT ISSUED----------------------- = - --- - -----• DATE-------------------: - Alterations and/or recommendations:------------ ---- ---- -------------•-----------------------------------------•------------•---_---= ...... ----------------------------------------=---------------•--------------- ------- ------- --------•---------------------------------------------------•-------------------------------------------------------•-----•--------- ---------------:--------------------------------------------------•------------------------------------------------------•------------ �� 1� �� Y FINAL INSPECTION BY:._ei Co__s----------- -==------------------ Date------------------------------------- SAN JOAQUIN-,LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street .132 Sycamore Sfreet', A , ' 814 North "C" Street Stockton, California Lodi, California a Manteca, California Tracy, California E5-4-2M Revised 1-57 F.P CO. /