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APPLICATION FOR SANITATION PERMIT Permit No....l�d (Complete in Duplicatel ' This Permit Expires 1 Year From Date Issued Date Issued pp Hca on 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___ -----------••--------------------------------- N'_ ,. -----•---•--------------•--••--------------------------------------------------- --------------- Phone = Address ............ -----�•• !^ -- ------------------ •--------------------------- •------------------------------------------------------------------------------------------- •-------- Contractor's Name---- ---- ------------S__, •7 ---------------------•--------------------------------•- -----. Phone----•--�f----��--=�Y'z.�G- Installation will serve: Residence ®•,,, Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other [] Number of living units: ---/ Number of bedrooms :_3- Number o1.f baths Lot size O0 #'t,2 a----------•--------------- ater Supply: Public system ❑ Community system ❑ Private Depth,"to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam []?. Clay Loam ❑ Clay ❑ Adobe 2]--T�ardpan ❑ Previous Application Made: Yes ❑ No 2 -"New Construction: Yes 2T No ❑ FHA/VA: Yes 0,.,. No [�-- TYPE OF. INSTALLATION 'AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 'Septic Tank:}' �� Distance fram nearest well ----------------- Distance from founds#ion--.__ �C:r Material------------------------------- I�io. of compartments --------------------------Size --------------------- -- ----Liquid depth = Capacity ,�.., -•----- --------------- Disposal Field: Distance from nearest well ------------------ Distance from foundation___ ---.-__.....__.Distance to nearest lot line ___.____--"___-- Number of lines -k -.-----j - ------{-------------- Length of each line----�(1------------- -Width of trench--3-_�-__-=:----u----- P ----------- length `4 -------------------------- e . �' �- --------------•------ Seepage Pit: Distance to nearest+well"--------------------Distance from foundation ------------------- .Distance to nearest -lot line :_-_---_-_------ ❑ Number of pits --A- --------------- Lining material--- Size: Diameter-, Depth - ---- esspool: Distance from nearest well ------------------ Distance from foundation. ---- .-------------- Lining material__.. I ___.__- ____.-___ _- -------- Size: Diameter----=- ---------------'-------------- Depth -------------------•----------- ------Liquid Capacity gals. Privy: Distance from nearest well--------------_.._-----"--------------" ---------------------------------------------------- Distance from nearest building ❑ .Distance to nearest lot line I ' Remodeling and/or repairing (describe)--------------------------------------------------------------------------------------------------- ---•-------•------------------------------------------- I ------- --------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------------- -- I hereby certify that I have prepareclAis application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules d- regulations of the San Joaquin Local Health District. (Signed)-------__ ---- --- --------------------------------------------------------- ------------------------------------------------------(Owner and/or Contractor) By:-------------------------------------------•------------------------------------ Tifle __ _ --- ---------------------------------- - (Plot plan, shoving 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 ---- REVIEWED---------------------------------••-------------------•--- DATE ----- �,J................ E -- I IS - ----------------------- ----- --- DATE -------------------------- -- - --- - ----------------------------------- BUILDING PERMIT ISSUED----------•-------(- - . ---••-----------•------- ----------------------------------------------- DATE --------------- ------------------= ='------------------- r -- Alterations and/or rsco endatio .1 --------------------- ------- �� 1 ��=--� ---- --------------------- -------------- ------- ------------------------ FINAL INSPECTION B �j �-Z�� - IV- t R Date. :------------------------- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American tr s ee+ 300 West Oak Street 132 Sycamore Strea+ 814 North "C" Street Stockton, Califor is Lodi, California Manteca, California Trecy;`•Cdlifornia ES -9-2M Revised 8 -'SYS; F.P'C.. ..- ` !6