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APPLICATION FOR SANITATION PERMIT Permit No. Complete in Duplicate) 3� 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 No. 549. JOB ADDRESS AND CATION---__:- -- -/ ------lj"_.-- ------- - -+ ---------------------- ----- . TIC Owner's Name---------- --••--• ---------------------------------—----------------------- --- ------Phone--------------------------------•--- Address-------------------------------------------------- ---_a, ------ --------------------------- •------------------------ Contractor's Name-------------------------�I __.---------------------- ------------------------------------------------------------ Phone-•----------------------•---------- y Installation will serve: Residence [f�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms -t----- Number of baths -)----- Lot size ---1)� ' - ----------------------------------------- Water Supply: Public system R--community system ❑ Private"❑ Depth to Water Table -------- ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe - hardpan ❑ Previous Application Made: Yes ❑ No Vew Construction: Yes ❑ NoHA/VA. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:. (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest welf-----------------Distance,from foundation_- -- _-------Material----------------.------_--__-----_--__.----- ---. No. of compartments--------------------------size--------- --- ---- ---- -Liquid dce th------------------------- Ca Capacity -- � ----- Disposal J Id: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- L Number of lines------------------- --------------Length of each line------------------------------Width of trench-------_--------------------------- Type of filter material--------------------------Depth of filter material-------------- Total length--------------------------------- ------ Seepage Distance to nearest well__--------Distance from/�foundation---'D------------Distance to nearest lot`iine--� __-__-___- ) ' Number of pits_j----------------Uning;material__ 4 -____,Size: Diameter-__'�_Yr-----------Depth---z,-_--------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------.-----Lining material---.----.----------.----------_-----. ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. ,j Privy: Distance from nearest well----------------------------------------------;_Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line------------------------------------------:------------------------------- ----------•--------------------------------------------------- Remodeling and/or repairing (describe)-----------------------------------------------------------------------------•------------------ -------------------------------------------------------- � -------------------------------•-----------•--------•-------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- --- --------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St an rules and emulations of the San Joaquin Local Health District. z: a (Signed)-- ! ✓ i ___._#_.______- _--------(Owner and/or Contractor) 11 A By:------------------------------------------------------------------------------------------------------------------------------------(Title)-------------------------------------------- - (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). F ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ' ------------------i------------ DATE-------=t ----- ------------ - REVIEWED BY---------------------------------------------- ----------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE--------------------------------------------... Alterations and/or recom ndations------------------- ---------- -----------t-- ------------------------------------------------------------------------------------------------------------- ---------------------------------------r-1-7 t'7TH---------5---------------------------------------------------------•--------------------------------------------------------------- -----•----------------------------------------------------------------------------------------------- ----------------------------------------------------------------- •----_•----------------- k ---•-•-••-------------•--------------------- -- -----•-- ------------------------------------------------------ ---------- --------------------------- FINAL ---FINAL INSPECTION-13Y 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 Revises 1.57 F.P.CO.