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APPLICATION FOR SANITATION PERMIT Permit No. _za# .. (Complete in Duplicate) bate 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. JOB ADDRESS AND LOCATION.___ -- Owner's Name----- ,-------/--------- -Y"!w-- - _ ---------------------- Phone. Address---------------t ----- r (/--/-A/.&----------------------- Contractor's Name--------------------4:2_V ------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence Apartment House ❑ C,,00mmercial El Trailer Court ❑ Motel El Other F]Number of living units: __/__- Number of bedrooms ___yllumber of baths ,- ___ Lot size ____ `_._ __ ��-__I-------------- Wafer Supply. Public system []/Commun'ity system E] Private E] Depth to Water Table __. _ ft. Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes U-I/No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: Aen o se�nk or'cesspool permitted ifpubliciewer is available within 200 feet.] Distance from nearest well_. i. ------Distance from foundation----LD-___ __.Ma�tef�,I____ __________ o. of compartments---------7r-y----�_ - Size__,3_�_sx9------_---Liquid depth-------Y"'-a----------Capacity____Sd+o -- -- Dis os I Field: Distance from nearest well_ ------ __Distance from foundation__ _ Distance to nearest lot line____ r----- Nurnber of lines________________ ___.__ ___Length of each line_________ Width of trench___ `_ Type ___Depth of filter material_____ _ __!r -----T e of filter material length-_____ r 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`-A__t_-_-------Distance from foundation_________________`.Lining material_______-___------_________-________ p ❑ Size: Dia me_ter._:---------------------- ------------Depth--------------------------------- - - -----Liquid Capacity-------------------- ----gals. Privy: Distance from nearest well------------------------------- '__----------Distance from nearest building �. ❑ Distance to nearest lot line-------------------------t----------------- ti Remodeling and/or repairing (describe) ---------------------------------------- ---------------------------------------------------------- ----------------------------------------------------- -------------------------- -----------------------------------------------------------------`-•-------•--------------- ------------------------------- a ----------- ------------------------------- �. 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. (Signed] Y -�--�� -- _ _ _ _ _ (Owner and/or Contractor) BY-------------------------------••-------------------------------------------------------------- -----------------------------------(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----- d --= - ------------------- REVIEWEDBY--------------------------------------------- ------ ----- --- - - --------------------=----------------- DATE----- -- ------------------------------------------------ { BUILDING PERMIT ISSUED------------------------------ -- --- ----------------------------------------------------------- DATE -Alteration s and/or recommend ions------------------ --------------------------------- --------------------------------------------------------------------•---------------------•------------- •-- ---------- --- - ---- --------------- ---- -----•--.-- -- - -------------------- ---- - - ---- - - - - - - - - -------- ----------- ------------------ - -- ---- -- ---- -#----- 'Z.�--- -- ------ FIN INSPECTION BY:. - ,DateCIE--- --- -- ----------di--------------------------------------: a SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street f Stockton, California Lodi, California Manteca, California Tracy, California E5_•--9•--2M•;'_ Revised 1-57 F.P.Co. 1