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v APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Duplicate} Date Issued ____-- --y1--J------- 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 OCATION.- Cd G-=: , "` r ----------- OwnersName------ -- ------ ---------------•------------ - ---- --- ------------------------------------- ' Phone----------•-------------`------•--- Address-------•--------- ---Y'-- ------ ------------- -------------------------------------------- Contractor's Name------- - '- Phone. Installation will serve: Residence/❑ .*Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot 1 ❑ Other ❑ Number of living units: --- Number of.bedroomsJ_._-Number of baths -o-- Lot size ___ __ _ __:_'___._____ Water Supply: . Public system 'P"-=ommunity system ❑ private�Depth to Water Table �/P 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 JrFHA/VA: Yes ❑ No 9 1 TYPE OF INSTALLATION`'AND SPECIFICATIONS: (No septic tank.or`cesspool permitted'if public sewer is available within 200 feet.) Sept' ,Tank: Distance from-nea'res't well__'`'_____Distance from foundation__-rJ'� ---_-__-Mate rel`__ ___- ----- No. of compartments---- , Size , Liquid�/depth Capacity s E� r i e Di osa Field: Distance from nearest well._��'_-_,--Distance from foundation___. Distance to nearest lot lieed__ ----- ---� � ♦ r Number of lines_____'______________ i___ Length of each line______/-_______________ Width of trench-,__ _ _____-____-____-."____ Type of filter material_ �1g -Depth of filter material__Af-----_____-_-Total length-----Z _'F'________________________ Seepage Pit: '—Distance to neares�ell----_- --�''Distance Bonnfou ation____----------------Dista�e to nearest I line----------------- g f ( Number•of pits_____________________Lining material _______.__ ___-_Size: Diameter -_ .--------.Depth-- r_ Cesspool: Distance from nearest well-----------------Distance from foundation-----"--------------Lining material--------____- __-__.__.____________-. ❑ Size: Diameter-------------------------- ----------Dept h----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest-well__': .: _'°'._.':_"----------------------__::Distance from nearest building------------------------------------------ Distance ________________ _______________________Distance to nearest lot line -�`--=------ =-- ----------------- ---------------------- -- 1 4 r + __ _____________________________________ Remodeling and/or repairing (describe):--- -------------- describe):___ - ------------------------ •-----=--- -•--------- - - ---------------•-------------------------- ----- •-- _ d - ._ --._ _______--------------------- I _____________ _I hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations f the San Joaquin Local Health District. Si nedrS` ----�-------`{9' '' �-Contractor) -�� Co tact By: , ------------------ -.ate '' - ------ (Plot plan, showing size of lot, Ioc 'on of system in.relation to wells, buildings, etc., can be placed an reverse de). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ------------ ---------- -� DATE----------' ---------------------------------------- REVIEWED BY--------_------------ - - ------ DATE----------'--- ----} BUILDINGPERMIT ISSUED------------------- ---------------- ------------------------------------------------------------ DATE------------r-----------------------=----------------------- Alterationsand/or recommendations-------------------------------------------------------•-•-------------------------------------------------....------------------------ ------•-•------------ ----------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- -"----------------------....------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ ------------------ -----------------------••-------------------------------•-••----•-----------------.-.."--------------------------------------------- F // FINAL INSPECTION BY:-"= y'� ! -.---- Date--/ ------ ---- C.7---- . - 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 . i 'F E5-9--2M . Revised 1-57 FY.CO.