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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 for a permit to construct and install the work herein described. This application is made in compliance with County Ordina ce No. 549. ? J08 ADDRESS AN CA ION---- -�(�'_�-- ------ -- -�----V----------------•------------------ ------------ - Owner's Name ------------------------- ---------------------------------------- ---- Phone Address---` - ----- Contractor's Name = ---- - --- Phone------------------------- - ------- -------------------•------------ - --------- Installation will serve: Residence ®-"A�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --_.__-- Number of bedrooms __X_ Number of baths /-__- Lot size 4949-- Water Supply: Public system WIGMmunity sysfem ❑ Private ❑ Depth to Water Table 4,,0 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe - fardpan ❑ Previous Application Made: Yes ❑ No Ik' New Construction: Yes.E] No [IR' %A.,4VA: Yes ❑ ! No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available witlyn 200 feet.) Septic Tank:A Distance from nearest well__ -----Distance ndation---j44P_-- of compartments-___. x._f' Size-- --_ - Liquid depth---- - _ Ca acitY yG*----- -- P -- Disposal Field: Distance-from-nearest well----- ,_._.Distance-from foundation____/-tel--__._.Distance to newest lot line-_--�_------_. Number of lines---------/-- Length of each line----_--fd.-�_---_-----_Width of`trench--- i� "______ ------------- Type of filter material-f yP �-------------.---Depth of filter material--- --------Total len gth_-__----'10 Ve �_ Distance to nearest well.._+-------Distance f m f ndation___-- r_�.Di_g ce_o._nearest lot line-- -or ------- ----- ")l Number of pits.--__--/----------Lining maferial-__._Size: Diameter_ D - Cesspool: Distance from nearest well-----------------Distance from foundation--------------.----. in�g material ❑ Size: Diameter------------------------------------- Depth ---------------------------------------Liquid Capacity- - ------ -----------gals. Privy: Distance from nearest well----------------- _------------------- -----.---Distance from nearest building-:-___.---------------------------------- ❑ Distance to nearest lot line---------_---------------------------- ___________ - ZeeRemodeling and/or repairing (describe}------------------------ .+ _- � �-�--------•-------------------- --------------------- --------------------------------•-----------------=---------------------- ------------------------------------------------------------------------•-------------- F i ----------------------------------------------------------------------------------------.---------------- } I hereby certify that I have prepared this application and that the work will be done in accordance wit San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) -------------------------- --- -- - -- -----...---- ------ an Contractor) By-----------------------•---------------------------------`--- - (Title)----- } (Plot plan, showing size of lot, location of m in.relation to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------•------------ DATE ----------------------------------------------------- ' REVfEWEDBY ----------- = --------- ------------------------------------------- ------ ---------------------- BUILDfNG PERMIT ISSUED --------------------------- ------------------------------- DATE--- ---------------------- -Al terations and/or recommendations---------------- -------------------------------------------•----------•---------------------------------------- ---------------------------------------------1• -----------------------------------------------------•------------------------------------------- --•------------------------------------------------------------------------------------------------ -------------------------------------------------•--------- -- --------------------------------------------------------- ------------------------------------------- '------------ ----------------------------- FINAL INSPECTION BY:. I ` l----------------------------- Date � _ -, ------------------------------•--.. SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Streets•' ,132 Sycamore-Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M Revises 1-57 F.P.CO.