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APPLICATION FOR SANITATION .PERMIT Permit No. ...�,�-1�!. (Complete in Duplicate) _ Date Issued6- --------------- Applica+ion 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 Or inance No. 549. JOB ADDRESS AND LOCATION_ ---------------- - ---------- - - Owner's Name- :--- - ? -- Phone Address-----------•--• -- ---•� ---------------------- ------------•---•-----------------•--•---........--• ----- ..--------•--•-•-•-•--•-----••---- Contractor's Name--- --------- ----•-- tI - '- E Installation will serve: Resident ❑ Apar ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: -------- Number of bedrooms ________ Number of baths ________ Lot size __________._-___-_____________________________________._.___ f 3 Water Supply:' Public system ❑ Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of,3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ; o septic tank or cesspool permitted if public sewer is available within 200 feet.) Se T k: Distance'from nearest well_________________Distance from foundation__ __.______________.Material______.______________.____________.___________- No. of compartments-------------------- • ------Size--.-•------_-----:--------------Liquid'depth--------------------------Capacity----------------------- isposal Field: Distance from nearest well_ --Distance from foundatiof___ _ ___________Distance to nearest lot�ine__> ._________ Number of lines___r_�........... ... .I�Length of each line______(0-a_. __- Width of trent .�7___________--________--__ Type of filter materiarAlll -Depth of Pilfer material___.�i _-.-_'____Total length__ _______________________________ See age Pit: Distance to nearest w _______Distance from o�pffoun d tion___ V�______ istance to nearest lot line________________ Number of pits.---'-/-.__'___:______Lining material111� ize: Diameter___..__ ._ p ------------------ I r I ' c1 Cesspool: Distance "from' nearest well-----------------Distance from foundation------------------..Lining material------------------------------------- 0 Size: Diameter-------- ---------- ------Depth--------------------------------------------------Liquid Capacity----------------------------gals. 1 ' .. Privy: 'Distance from nearest well----------_----------------;-__---_-------------._Distance from nearest building--,_____-_----_-_-________________.____._- ❑ Distance`to nearest lot line------------------------------------------ ------•--- ------._._-..._..----------------I---------`------------------------------------------- Remodelingand/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- 3 l ____ _ _ _ _ ______________________________________________________________________________________________________.._______.__________._____________________...____ 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. - (Signe�d)..._.k- -- ) ------- ------------------------------------------------------------------------------ ---------------(Owner and/or Contractor) B • ; x - {Title)_ K (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placedon reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY c ------------------ ---------•-...--••-------...-_ DATE.._,`Z_"_3L-r•------------.._. f. ------ DATE---------------------------------------*=------ -•- REVIEWED BY----------------------•----------------------�- --- ------------------------- BUILDINGPERMIT ISSUED--------------------- -.------------------------------------=------------------------------ DATE-------------------------------------------------------------- Alterations and/or recommendations:----:--------------- ------- ---------- =-F---------------------- ----------------------------------•-------•------------------------------------- -------------------------------------------------------------- ------------------------------------------ L1.1 ---------------------------------------------------------------------- ----------------------------•------------------•---.--•-----------•-------------------------•.---------•---•---••--------------------------------•---•- r� ----------------------------------------•-•-------------------------- -------------------------------------------------------------------------------••-- FINAL INSPECTION '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 ES-9-2M ; . Revised W-2100