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A-�N APPLICATION FOR SANITATION PERMI ' Permit No. .`--_---_ I r/ (Complete in Duplicate) II I 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 Ordinance o: 549 ff'2 dJOB ADDRESS AND LOCATION________ l - -- ----- - - ------ - -- ----- P_- --- Owner's Name _ y _ --------------- Phone Address-•---------- Contractor's Name---------- - 7------- ---=---- --------------------------- one Installation will serve: Residence ®/Apartment House ❑ Commercial E] Trailer Court-❑ Motel ❑ Other Ej Number of living units. __/_. Number of bedrooms _��Number of baths F Lot size --------------- Water Supply: Rubfic 'system �mmunity system ❑ Private ❑ Depth to Watt Table -------- ft. Character of soil fo.a.depth of 3 feet:A E]Sand Gravel Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ad ® obe �ardpan E]Previous Application Made: Yes E] No %w Construc+ion: Yes o ❑ FHA/VA: Yes ❑ No-V,--' TYPE OF INSTALLATION AND SPECIFICATIONS:': r (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic an C Distance from nearest well_______________Distance=from foundation_________________Material_____________.__.______________ --------------- No. of compartments..---------_--- ----- -- ----__--Liquid depth--------------------- . _Size----=--•--------------- -----Capacity------------- -------- e Disposal Field: Distance from nearest vrell---------------.Distance from foundation-----------------_Distance to nearest lot line______-- ap� Number of.lines----------- ---"-----------------/Length of each line------------------------------Width of tre,nch----------------- . Typeaofil#er material__.__-'----------- ----- , Depth of filter material'__________---_-_-- -Total length-_-------------------------___----/ Seepage it: Distance to nearest well__ ML}istance fr m f undatian_f�_.�.°_____.Dist��ce to nearest lot line___ ______._ Number of its /________________Lmin m /� -- _ ud' p g ma el CSC A ----Size: Diameter--33-------------Depth- _;23 ----------------- Cesspool• Distance from nearest well-----------------Distance from foundation-------------------_Lining material--------_- --._____._______----.___. ❑ Size: Diameter-------------------------------------De Depth Liquid Capacity-- --------------- ----gals. Privy: Distance from nearest well_______________ Distance from nearest buildin ❑ Distance to nearest lot line-------------------- ----- g - -------------- . Remodeling and/or repairing (describe)-------------------------------------- 7- ----•-------- ----- ------------------------------•---- �. ------- -----------------------------------•----------- -`------------------- - - I hereby certify that I have prepared this application and that the work--will be done_,in accordance with San Joaquin Count ----------------- ----- ••--- --- - � he San Joaquin Local Health pistrict. _ •� ` ordinances, tate laws, and rules and regulations of t ( Signed)Si ned __ 'jam:._. ,y-` '--•"=-- -"=3"=---` -------------- ------ ------------------ --------------------------------------(Owner and/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--------------------- - --- IEWED, BY----------------------------------------------- DATE- /�:------------ BUILDING PERMIT;ISSUED---------------------- - - p a = DATE C - -- -- Alterations and/or recommendations________________________________________ --------------------------------------- - ----•----------------- --------------------------------------------------------------•------••----------------- - ----------------- �`_�U- _---- ----_------ .__ --- -- - ------•--------- --•-----•---------------------_--- -•- ----------- ----------- FINAL INSPECTION BY:-_------ _------ _--- �-17 ------------ Date -------• --• ---------- SAN JOAQUIN LOCAL EALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street I Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M , Revised 1-37 F.P.CO. l