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- l APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Data 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 Coun y Or nd ce No. 549. JOB ADDRESS FAC TION------ - ....... 7 th- zTI'-------------------------------------------------------- -Owner's Namey- /` !- - --- ----- - Phone ®_Address------------- / � Q Contractor's Name---------------- = ---------------------------------------------------------------=-------------------------------- Phone----------------------------------- .. Installation will serve: Residence Q/Apartment House ❑ Commercial ❑ Trailer Court ❑ Mqf Other ❑ Number of livingunits: s=--`Number of bedrooms I ,f�j' baths �-Lot size ----1_--- ---------------•- Water Supply: Public system Community system ❑ Private ❑ Depth to 'Water Table -------- ft. l 'I : : Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe B-/Hardpan E]Previous Application Made: Yes ❑ No New Construction:, Yes ❑ No ❑ FHA/VA:,Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS.-.;,, r - (No septic-tank or'ces'spo I permitted if{public sewer is available within 200 feet.) eptic Ta c Distance 'from nearest well=::___--A:_____Distance t'r'om foundation--------------------Material____------------- ____________ p No. n cf from nearest weft_ __________ -Distance from four Liquid�ep�h-Distance to nears t lot ine__r� L m artments_____ ___- Size_____-.____ / t r ndatio s osa F' J Distance of lines______.___ _. --____ ,_�,Length of each line_____��__ __ _�_____.1Nidth of trench._ Number / _ /p Type of filter materiaL_ ':Depth of filter material / Total length----- ---------------------------- Seepage -- ------------------------ Seepage Pit: Distance to nearest well___________ Distance from foundation--------------------Distance to nearest lot line--___--___.______ ❑ Number of ---------------Lining material-----------------------Size: Diameter------------------------Depth----.--------------------------- Cesspool: Distance4rom nearest well----------------Distance from foundation-------------------.Lining material___________________________-________- �. ❑ Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity----------------------------gals. Priv Distance from nearest well_________________ ________-___.____________Distance from nearest building______.._-----------______________.____- Y� . tonearest,lot line---------------------------------- - --- - -- ------------------------------------------ - ---------------------------- Remodeling and/or repairing fdescrihe):---------------------------------------------------------- -----=-----••--•--------------------- -----•------------------------------------------------------------------------------------------------------------------------------------------------•------------------- ------------------------------------------------=-----=------------=-•------------ _____________ -------------- - v . I hereby certify that I have prepared this application and that the work will be done in accor_dance.with San Joaquin County ordinances, State law nd ules andye ulation. f e San Joaquin Local Health District. (Signed)--------�----------- ---- --------- ------- -` -----------------/`- - -------------------------------------------------(Owner and/or Contractor) By:----------------------------- --------- -----------------------3,--------------------------------------------------------------------(Title)--------------------------------------- -------- --- (Plot plan, showing size of lot, 1 cation of sysfern in relation to wells, buildings, efc., can be placed on reverse side). F911 DEPA TMENT USE ONLY REVIEWED BY - ' DATE to --------------------------- APPLICATION ACCEPTED BY BUILDING PERMIT ISSUED------------------------------- -------------------•------------------------------------------------- DATE- - - -- '1 ---------- --------- DATE-------------- - ------------------------- ---------------- I Alterations and/or recommendations--------------- ---------------------------------------------------------------------------------------------------------------------------------------------- a _.---'---------------------------------------------•-------------------------------------------------`-------------------------------------------•--------------------------`-------•-------------------------- ------ --------------------------- ---------- ------- -------------------------------------------------------------- -'-------------------•-••--_--------------------------...----------_------------------...--------------------•----_-----_------------------------------`-- ---------------------------------------------------•-------- +Ml� FINAL INSPECTION BY:. -i -------------------------------------------------- Date--- -- f�J - - ----- -------------------------- r-------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 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 EP,CO.