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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Issued d 2 `-. Application is hereby made to the San Joaquin Local Health District for a j rmitt I c Duct `a l ih wo, herein described This application is made in compliange with Cou. 0,rdinanc No. 549. a I .00 JOB ADDRESS D LOCATIO e - = - Owner's Name_: . " Phone w - hon �. Address----- r - - -�: = Phone----•------------•------- Installation will serve: a Residence partment House ❑"+Commercial ❑ Trailer Court [j ``Motel E] Other El # ` ' N mbar fi�aths _ .____ Lot size ----l-- - -- - = - --------------- Number of living units: _1____ Number of bedrooms . ---------- Water Supply: Public system ❑ Community system ❑ private 1 Depth to Water Table"------ ft. Character of soil to a tdepth'of 3 feet:' Sand ❑ Gravel n Sandy Loam E] Clay Loam [Clay ❑ Adobe ❑� Hardpan ❑ Previous Application Made: Yes ❑ No R( New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: r [No septic tankior'cesspool permitted if ub�ic spe is available within 200 feet.) x � �.. �. r Septic ank: Distance from nearest wells istance from foundation_ . Material • ► � Size------------------------. q c I? apautY No: of compartments_---_-_.___. t___.e_ Liquid th_ __/`}__-- � `:Uistance:to.nearest lot line _ Dispose ield: Distance from nearest we __ Distance.fram foundation_ _ _ -----Len th of each line----------. _ Width of trench--------. - ---, Number' of lines--.--'---- --- - ------- g ---• a � Type of-filter materi p Total length__________-----_ _ __________ t �• th of filter maternal- _._ _ : ----- � , ssTanc rorn•foundation_______ _________.Distanr�e to nearest lot line___ Seep Pit: Dist ance to nearest well-- - _:___ ____ Number of pits---- _- --Lining material----- _-- -�- ize: Diameter---- - Depth----.-.- - ____ Cesspool: Distance from nearest well________________Distance fro o ation_____..__--________.Lining material_--__..___________---___________.___ I ❑ Size: Diameter------- ------ ----- Depth-----------------------•----------------------- Liquid Capacity gals. Distance from nearest buildin ___________________ Privy- Distance from nearest well ------- <i------------------------- - 5 ❑ Distance to nearestlot�line:_.m:"'='--------==:'---"----- ----------------------------------------------------------------------- Rema lin nci/or repairin dv`scribe)------------ -----=---{------------= ------------------•----------------•---------=, = ---------------------••--------------- - ------ ------ ---- ---- . --------------- - 1. _ 1 hereby certify that I•have prepared edi ns application the San Joaquin Local work Health he-don�`}n accordance with San Joaquin County S t ,of ordinances, State laws, and rules angula } and/or Contr Signed]_ _` ------------`--------- ----------------------------------------(Owner actor) f ----- --------- ------------------••--- ------------------- ---(Title) {Plot plan, showi c size of lot, location of system in relation.to:wolls, buildings, etc:,.•can_be placed on reverse side). 1. =— * FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE_�---------------------------------------------------- REVIEWED BY = DATE � BUILDING PERMIT ISSUED------------- -- ---------------------------------------- DATE---- Alterations and/or recommendations:--------------------- --••--• ---------------------•---------------•---•------•------------ --------------------•• --------------------------------------------------- ---------- -------------------------------------- _ 7 gay FINAL -INSPECTION BY..; = --------- - - Date ----- e+ 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 , Revised 1.57 EP.GO.