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APPLICATION FOR SANITATION PERMIT Permit No. .-.�- _ _5 (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 Ordinance No. 549. JOB ADDRESS AND CATION--- G, v--- '""� Owner's Name-------- - Phone. AddressQ��----;7---------- -------------- 4---- ----•-•----------------•---- Contractor's Name------------ - - ---- ---------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---4___ Number of bedrooms __J Number of baths ___I__ Lot size ----- -___________________ Water Supply: Public system ❑ Community system [I Private WDepth to Water Table,?_ ft. Character of soil to a depth of 3 feet: Sand E] Gravel X San6? Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No)0' New Construction: Yes ❑ No FHA/VA: Yes ❑ N05� TYPE OF INSTALLATION AND SPECIFICATIONS: (N P septic tank or'cesspool permitted if public sewer is available within 200 feet Septi T Distance from nearest well-----------------Distance from foundation__._____.______.Material------------------------------------------------ _ No. of compartments--------------- -Size-----•--------------- -----------Liquid/depth--------------------------Capacity----------------------/-- Disposal Fie Distance from nearest well-_ _____ ____ __Distance from foundat* n �a istance to nearest lot Number of lines_________ Length of each line-,., -- _�_-Width of trench----Z------------------------- i - _---_______ ________ � Type of filter material Depth of filter material__1._ __qp_.___-_._.Total length_______ _ a00eeoag, Pit: Distance to nearest well___ ______ ________Distance from foundation__LU__.__ Distance nearest lot ine. ___________ (� Number of its----/_______________ : V p 5' m terA �_ Depth Cesspool: Distance from nearest well_________________Distance rom f�oun o ___.__________.____.Lining material_______________..___._______________. ❑ Size: Diameter-- ------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______________________________-__________ ❑ Distance to nearestIgt lire-------- -------------------------------- ---------- --------------------------------------------------------------------------------------- Reem-'ode�llin�g and/or repairing (describe):-vim �9�-�'Q-�� ------- •-- - ---- -�--------------------- --•----------------------------------------------------- } - ---------- I hereby certify at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws, and 4ruland regulations of the San Joaquin Local Health District. w (Signed]______ __ _ _ _ (Owner and/or Contractor) By:------------ --- ------ ......... -------------------------------------------------- ----- -----(Title) (Plot plan, showin 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-------------------------- - ------------------------- REVIEWED BYDATE ------------------------ BUILDINGPERMIT ISSUED--------------------------------------- - --------- ----- DATE------------------------------------------------- ------ Alterations and/or recommendations------------------------- --------- ---------------------------------------------------------•----------------•------------------------------------------------ --------------------------- --------------------------------------------'----------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--- -------------------------------------------------------------------- ---- ----------r"-,° ----------------------------------------------------------------------------------------------------------------------------- F1NAL INSPECTION $Y:. 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-4-21x1 Revised 1.57 F.P.CO.