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APPLICATION FOR SANITATION PERMIT Permit No- .__.____ ,A �r (Complete in Duplicate)„ Date Issued 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 1. / O Ordina co No. 549. �_____ ------------ JOB ADDRESS AND LOC TION_____ Id-, - Owner's Name-------4/�-t E------- ---------. -------- - - ------------------------------------------------- Address---- ------------- ------- --- -------------------------------------------------------------------------------------------------- Contractor's Name------------------ ---- - ---------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel '❑ Other ❑ Number of living units: -/- Number of bedrooms __ ____ Number of baths _ _ Lot size - _} _____________________ Water Supply: Public system Community system Private ❑ Depth to Water Table ft 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Loam E] Clay ❑ Adobe Fq-11ardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or''cesspool permitted if public sewer is available within 200 feet.) 1 nk� Distance from nearest well_________________Distance from foundation--------------'__*.Material-i---------------------------------------------- No. __________.______._______-__________..__.No. of compartments--------- Size--------------------------------Liquid depth----------------- -------Capacity----_----------------- Fi Distance from nearest well_________________Distance from foundation------------------".Distance.to nearest lot line_________________ Length of each line____________________________.Width ofitrench_.________-_-__._._____._____. Number of lines----------------------------------- �.. ---- Type of filter material_________________________Depth of filter mai-erial____________: length----------------------.------------------- Seepage,-Pit: _________________Seepage it: Distance to neares.twel _ __Distance f m f�ndation-- Distance to nearest lot line_ Number of pits_____�_____________Lining material___ -__Size: Dameter_,_3-` -- De th- _ -i-V Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material-___.__--------------___.---_ ❑ Size. Diameter----- ------------------- Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___________----------____________________ \ ❑ Distance to nearest lot Ilne----------------------------------------------------------------------- -----------------------"---------------------------------------------- , Remodeling and/or repairing (descri4�e):--__ ----- 1. ----- ------------------------------------------ ---------------------------------------------------------------------------- --------•--------------•----------------------------------------------------------------------------------------------------------------------- ------------------------------------- ------------------------------------------- ---------------------•-----------------------------•-------------------------------------------------------------------•------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ' ordinances, St a aws, ani,ru es.and regulations of the San Joaquin Local Health District. Si ned - ----- Owner and/or Contractor B /' J (Title} - -------------------------------------------- Y•--------------- 4' --------f ^---------- - L. � ------ (Plot plan, showing size of lot, location of sy m in relation tc wells buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------------- --- --------------------------- ----------------------- DATE------ ---------- -------- -------- -------BY--------------------------------------------- -- - --- -- ----- ------------------------------ DATE ---------- ------------------------ BUILDING PERMIT ISSUED -- ---- - --- ---------------------------------------------------------- DATE ------------------------------------- Alterations and/or recommendations:________._ _ -------------------------••------ -------`-----•------------------ ---- ------------------------------------------------------------------------------------------------------------------- ------ --- ------- ------ ------- -- - ----- ---- __ ----- --------- tp - ---- -- -- - --------- -------- --- ---- =- -----Vii''-rte _ ---- ---• -- - --------- - - - - -- =---- F NCTION BY: •- ------�--------• ------------- Date .�• SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C” Street S+ock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.p,Co.