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APPLICATION FOR SANITATION PERMIT Permit No...... (Complete in Duplicate) ) bate Issued Application is hereby made to the San�Joaquin`Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance'No. 549. bAL JOB ADDRESS AND LOCATION.. . _ - ''------------------ ------- --------- 1 Owner'''s Name f `. = Phone _ Address--------------— �-- ----- = -----�•------- -�__ =' } Contracto'r's Name------- ------- Phone Installation 4411 serve: , Residencei % Apartment House [ICommercial E] -Trailer Court [I Motel [IOther ❑ Number of living units: -i------ Number of bedrooms __°Z Number of baths)_�---_ Lot size __--�_�'___-�- ---an owww ... } .. .,r Water Supply: Public system '❑.. Comm un`ity'system El PrivateDepth`to Water Table,% _ ft.. F Character of soil to a depth of 3 fee+: Sand ❑. Gravel ❑ -Sandy'Loam,❑ .Clay Loam ElClay ❑ Adobe Hardpan El4 Previous Application Made: Yes El No New Construction: Yes N E] FHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) eptic Tank: Distance from nearest well__LD---__-Distance/from foundation---1.t�-_. -__-_.Material__�Q-1 ---- No. of compartments---------/------- ------Size---,,,�--1�----------------------Liquid depth--- ------------------------Capacify_Ir.In-------- Disposal Field- Distance from nearest well___ __--_Distance from foundation__�_b---__-_-.-_Distance to nearest lot li�-e--- 1 -- - ngth of each line_____- ,___�_______;___._ Width of trench:___ _____- �___________ Number of lines_-_--�-L.R_ -e #f0f'filter m terial____._I__�.-�`___-total length------- ----------------- Type of filter.material ------- arest well ---------Distancefrom foundation-.. to nearest lot line__-_--_._-------_ Seepage Pit: Distance to ne �} El -..Number of pits------'--------------Lining material Size: Diameter Depth Cesspool: Distance from nearest well---------------: Distance from foundation_---_,_,-_--._-_---.Lining material--_--.____----_______.__________._._ ❑ uSize:;Diameter- ------------------- ----------------Depth-------------------- ------------------- ----Liquid Capacity-------------- ---------gals. Privy: Distance from nearest well-------------- ----___---_--..__-_--_---_----Distance from nearest building------------------------------------------ h ❑ Distance-to-nearest jot line---------------= =--------------------------------------------------------------------- -------------------------- ---- Remodelin and/ r repairing [describe]:_ _ _ __. f " -. _ �? ----- --------•- --- ------ - ----- - (]-71 - - , rt-_ -- ---•----- ------------------- ----- i � ---------.-----------•---------- -----•-------------------------_ -. _ - �. _ _ _ _ __ _ __________________-------------------------------- ------------------------------- ____________________________________________________________________________________________ _____________ ________ ______ __ _ ___ __ I hereby cerfi that 1 have'-prepared this application and that the work will be done"in accordance with San Joaquin County he San Joaquin Local Health District. ce5A fate laws and rules and regulations oft - � � q g - or �nan � (Sign ad � ---- ------ Owner nd/or Contractor) By----------- ----(Title)------------- (Plot plan, showing 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--------------------------- }--------------------------------------- ---•----------- DATE REVIEWED BY DATE - ---------- --------- -- --- ---------- _ BUILDING PERMIT ISSUED------------------------------- ✓------ --------------------------------- DATE Alta afions and/or recommend afions:--------------------- `--- --------- ----- -------- --- ------------_-------------- •-----"�--- ,, .. . -�. .. ----- �,�,,, — ---------------------------------------------------------- ------ ------------------- -------------------------- ------------------------------ ------=---------------------------- ----------------- ----------------------- --------- FINALINSPECTION BY---------- --------- r---- ---------=--=------ --------- Date__:��-------------- ----`---------- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California M Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO.