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APPLICATION FOR SANITATION PERMIT Permit No. "f----3.`'......... (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 Ordi ante No. 549. ^ • --' ---------r- --•-Wit-?�i9"•-.� --�--`--- �----------------------- JOB ADDRESS AND LOCATION_.__ - ---�---- ---- -- Phone Owner's'Name___ ----------- ---- - -' -- ---------- _" Or Address--� ------ ----- ,1 Contractor A s Name___-__ .. --- -• t Men [] Gm--- ----- t-House, omercial•❑ � - railer Other Installation will serve: Residence ❑ " _ Number of baths _"/-_ Lot size __�r.�-�-r-�-- _._ ------------------------- Number of living units: ,�_-- Number of bedrooms Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table,�ft. Gravel E] Sandy Loam ElClay Loam [IClay E] A,lobqo Hardpan Character'of soil to a depth of 3 feet: Sand ❑ ❑ Previous Application Made: Yes E-1NoXI New Construction: YeXs No''❑ FHA/VA: Yes ❑ N TYPE OFIINSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available ithiti'200 feet.) Septi Tank: Distance from nearest wel _________________Distance from foundation____________; ;". Material__________ ' No. of compartments--------. ---------Size--------------------------- Liquid depth_ Capacity = Distance from nearest well________________ Distance from foundation__________________.Distance to nearest lot link "3 Dispo I Field: y CQ Numberiof�lines----------------- -----------------Length of each line_---------------------- Width of trenh_"_-""•"""--• \ Type of filter material- ------------------------ f filter material__________-_________-Total length____"_ Depth O --- ,q j ! f - Seeps e Pit: Distance to nearest well_ ,ter Y� Distance.from.f dation c ,bfstance to ne reef lot ine___ Number oft is----- _Lining material __- - ----Size: Diameter__��---- Depth- __- Cesspool Distance from nearest well._______--______Distance from foundation___-_________-____Lining material__._- L--t ----------• - t` ❑ Size: Diameter - _--Depth----------------------------------------------------liquid Capacity----------- ------•galls. -- ---------------------Distance from nearest buii&ng-----------------�-- Privy: � Distance from nearest well________________________ -tel ❑ ' Distance to nearest lot line.------ - ---------•--------------------------------------------------•------------ I -" -- --------------- Remodeling and/or repa describe .� Ig / p g � �= ------------------------------------ ------- f ` ------------------------------------------- -------------------------------------------------------- ve p epared his a lica ' n and that the work will be done in accordance with San Joaquin County I her+zby certify that I have , k ordinances, State i and ule a d re do of San Joaqui Local Health District. ------___ ___( nd/or Contractorl .. =F ------------ (Signed). .+_ --------- ---------------------------- ------- _ _ _ ___ ------------------- - --(Title -- - - -- -- r -- ----------------------------- [Plot pla s ow' size of ocation of system in relation to wells, buildings, etc., can be p ted on eve °.ide. { FOR DEPARTMENT USE ONLYi + ' _ . ----------- ----------- ------ DATE------ ---- --•---�--_--------- -- APPLICATION ACCEPTED BY,------ --- fi �'"„"`� ------------------------------ f* ' REVIEWEDBy--------------- -------------------------------------- ---------------------- ----------- c TE BUILDING PERMIT ISSUED-----1------ ----- ----- - ------------------------------------ ----- ------------------------ Alteration's and/or recommendations---------------------------------------------------------------------0...,� - - - --- -- - _ - ----------•------- �. _ 0. _____________________ ----------r` `----------------------------------- I ------------------------------ =r; ' - - •----- --- FINAL INSPECTION BY____________ _____ ____ __ _ ----------------•- "- Date-- ----j SAN JOAQUIN LOCAL HEALTH DISTRICT 132 5 camore Street 814 North "C" Street 130 South American Street 300 West Oak Street y Tracy, California _ Stockton, California Lodi, California Manteca, California ES-9-2M Revised 1-57 F.P.CO. �fi