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f � . y 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 County Ordinance No. 549. r JOB ADDRESS AND TIO ✓ _s_ _ ., _ _-____ / N Owner's Name = ----------- ----- ----- Phone---------- ... ---•---------- , Address --c- -- --------- -- ------�---------------------------•---------------------•--------------•--•------•-------...... -------•----- ------- Contractor's Name = -- Phone------------------------ -------------------------------- --------- Installation will serve: ResidenceEr--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ other ❑ Number of living units: _- -__ Number of bedroorrss _ `/ Number of baths __/.__ Lot size Water Supply: Public system '[ -ommunity system ❑' Private ❑ Depth to Water Table X / 2'0 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ . Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No g4w'-New Construction: Yes g?'-No ❑ FHA/VA: Yes A__1T0_❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well____��___Distance-from`foandation____� _______.Material--__- _ ________ [L�� _ ____o_ No. of compartments_.✓________________Size___ depth__-_ Ca pacify__ __h------------ Disposal F' d: Distance from nearest well._._ ___._.Distance fromfoundation---/F---------Distance to nearest lot Ilie---AP----- . Number of.lines------/-__--- _ _ Length of each line_=__• M____.----------.Width of french__�! ____------------- _____ Type`of filter material _ _ Depth of filter material_/,��l___�___Tota1 length------- - Seepage Pit: Distance to,.nearest well-___________ ________Distance from foun tion_---�,�__ ___.Distance to nearest lot line_--�-_--_- I Number of its____f_ ' Linin material/,/ DiametEr__ �__-_De th_-_ _- ! _____________ p --- 9 � p ----- Cesspool: Distance fi'om nearest well-----------:-----Distance from foundation--------------------Lining material------------------------------------- CIIN ❑ Size:'Diameter------- ------------------ -----------Depth-------------- -----= -- -------- Capacity - ------------------------- Privy: Distance from nearest well----______---------------------------------:____.--Distance from nearest building_____-_____________-___________-__-____--. \ ❑ - Distance fo nearest lot line----=------=---------- - ---- ------ --------------------=----- ------------------------------------•---------------------------- V Tom_ J � Remodeling and/or repairing (describe):------- � ' ------- f ----------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------ - ---------------- ------------------------------------------------------------------------•-------- ------------------•------------------------ ---------------------------------------•--------------- I hereby certify that`I have prepared this application and that the work will-6e, done in accordance with San Joaquin County ordinances, State laws, and 0les and regulations of the San Joaquin Local Health District. Signed) �r �--'1' - ------- ontractor ( -•----------------- ( 1 I By:---------------------------------- -- } -------------------------------------------------(Tif le)` �l �,d.] �--- (Plot plan, showing.size of lot„I cation of system in.relation`to wells, buildings, etc., can be placed on revers FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------•------- ---------------------•------------- ------------------------------------------ DATE--------------- F ,l----------------- REVIEWED BY----------------`--------------------- __ DATE--------------- BUILDING PERMIT'ISSUED------------- ---------------------- ----- ---------------------------------- DATE----------------- r Alterations and/or recommendations------------------------ - -- - -- ----------------•••------------------------------------------------ -------------------------------•------- ------------------------------------------- - ------------------------------/---------------------------•---------------•- -----------•--------------------•------•---------- -- ------=----•---------------------------- -------------------------------------- ----------------- --------------•----------------------------------------------------------------------------=---------------------------------------------- ---------------------------------------------------------------------------- r-4 FINAL INSPECTION BY:. Date----------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street a 132.Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9---2M Revised 1-57 F-P.CO.