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APPLICATION FOR SANITATION PERMIT Permit No. ..1�- - I..-. " (Complete in Duplicate) Date Issued 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 Ordinance No. 549. dEv JOB ADDRESS AN LOCATION-f- -- .1_.------1 ------------------------------------------------------------------------------- Owner's Name----...r . ^^ ----------------------------- ---- ------------ ----- ---------------- Phone--------------------------------- Address-----� ---------- ---------- ------------------------------------- - Contractor's Name------- -- ----------- ------------------------------------------------•----------- ----- Phone Installation will serve: Residence Apartment House ❑ Commercial ler Court ❑ Motel ❑ Other ❑ Number of living units: __ '__ Number of bedrooms --�Number of baths -2, Lot size ----/A Water Supply: Public system 0mmunity system ❑ Private ❑ Depth to Water Table j--Off. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ,Clay ❑ Adobe t'!'Ta`n ❑ Previous Application Made: Yes ❑ No Rga. 1`ew Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep ' Tan Distance from nf earest well-----------------Distance from foundation--------------------Material___________.________________--_____..__________- �` No. of compartments..,......-.....--------Size-----..---------------------.--_Liquid depth--------------------------Caacit Disposal Fieo,,: Distance from nearest well_________________Distance from foundation-------------.__._-.Distance to nearest lot line____-__"-___--_-- ""� Number of iines----------------------------------Length of each line------------------------------Width of french------------•---------------------- ,2, Type of filter material----------------_-------_Depth of filter material----------------------- length______.___________.________________._. Seepage Pit: Distance to nearest well_ _. __._._ Distance rom foundation--n4- 0---?_Distance to nearest lot line._et.1----- Number of pits.'------t---------Lining material--- __-Size: Diameter__.__ Cesspool: Distance from nearest wekl-----------------Distance from foundation_---- ------------- Lining material..__.._______:______________________. ❑ Size: Diameter--l--------------------------- -------Depth----------------------------------------------------Liquid Capacity----------------------------gals, S Privy: Distance from rearest well ____________------------------------------------Distance from nearest building-------------.----------.--------------_-. N ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------- J ----------------------------------- Uj Remodeling and/or repairing (desclibe):----------------------------------- - --------------------------------------•-•--------------------------------------------------.....---------..-..._. ; I I 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 regulations of the San Joaquin Local Health District. (Signed)-- - - ------ ---------------- r Contractor) .. '------------------------------------------------- Title---------------- ----------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r t ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -- ----- -----I-- ---- ------------------------- _---- .-------- DATE........ ----------- -- REVIEWEDBY------------------------------------ ------ - ---- ----- ------------------------------------------------------------------ DATE --- BUILDING PERMIT ISSUED----------------------------------- --- - DATE._ - --��---------- Alterations and/or recommendations---- ---------------- -------------------------------------- -------------------------- --------- - ---------- ---------------------------•-------••---------------------------------------------------------------•------------------•------------ ________________ ------------ - - _....__.._-______.__._--------------------------------------------- _._-------------------------------------------------------- --------- --- -----.-__......_......__.------------ ._. ______________ __ __� '___��_._ �___� t __p__..__ ........ ---•--•--•-------A .-- 6 o---------- - .4 FINAL INSPECTION BY:--------- --------------------------------- Date.----f--z- s-j55 SAN JOAQUIN LOCAL HEALTH DISTRICT t h. 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 15544k AT-COD 12-Sn