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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) AVL / Date issued __----1_-3.1_�•. 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 o. 549. JOB ADDRESS AND O ATION---------/ff Owner`s.Name--- �� t/ ------------- Phone- Address Address------ / --------- ---- ----------- - - - - -- -- -------- ----- - Contractor's Name---- ------------- -- - Phone_ Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Cour} ❑ Motel ❑ Other ❑ Number of living units. -__ -_ Number of bedrooms,,eF'-- Number of baths ---/-_ Lot size Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ AdobAr Hardpan ❑ Previous Application Made: Yes ❑ No>� New Construction: Yes No ❑ FHA/VA: Yes ❑ N01-K TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) eptic T nk: Distance from nearest well-----------------Distance from foundation--------------------Material __-----____------_.___-_- No. of compartments-------------------------Size--------------------------------Liquid depth------------ -------------Capacity------------------- Disposal 1 'eld: Distance from nearest well------- ------Distance from foundation--------------------Distance to nearest lot line----------------- Number __--------_--_.Number of lines----------------------------`---'Length of each line------------------------------Width of trench Type of filter material--------- ------------_Depth of filter material----------- __ otal length-_--_---._------_-_._--_- ---------------- Seep�ge Pit: Distance to nearest well- v '.___Dista e from f� n atior Distance to nearest lo# line _. - �'j`— Number of pits----- -------------Lining materi I ___ _ _Size: Di eter--- -- ,�- --_,Depth--__c�Gs� .- w, , Cesspool: Distance from nearest well_--._-----_-.--Dista ce fro oundation------_-------_---.Lining material-------------------__--------__-----. ,. ❑ Size: Diameter--------------------------------------Depth-.--------------------- Liquid Capacity gals. Privy: Distance from nearest well------------------------------------------------ - --Distance from nearest building------ ----------------------------------- n uilding--------------_----------------____-- ❑ Distance to nearest lot line----------- -- ------------------------------ --------------------- --- Remod li nd/or repairing (describe:_ r r --- - --- -- ------ -------- _ ---- - ------ ----------------------- ------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I herey certify that I have prep red this applicati n and at the ork will be done in accordance with San Joaquin County ordinances, St laws, d rules an a ations of t e San aquin cal Health ' 'ct. {S i ned 9 )----- ----- -- -- - -- -- - •� ---- - ------ - ----------'/---- ------=•'------------------(Owne nd/or Contractor BY: -- ---- --------- - Y -- - - -- ---------------------------------------------(Title -- - --------------------------- -- (Plot plan, showing siz io , f Ceti o o system in relation to wells, buildings, etc., can be p ced on ever side-. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y_ -•------- ----------------------------•--------------------------------•--------------- DATE_�'-- ------------ --- ------------ { REVIEWED BY --------------,------------------ --------------------------------------- DATE --`-- ------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATES _.. terations and/or recommendations:----`---------------------------------------------------- =- -- ---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------- 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 1-57 F-PCO.