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/ APPLICATION FOR SANITATION PERMIT Permit No. _�� (Complete in Duplicate) Date Issued S .•-�__. 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 LOCAT N ---- -- ----------------- <... --- . ---- ----- ............................ ............. OL Owner's Name------. '---------------------- --------------------------------------------- Phone.................................... --•• • ------ --------- -- Contractor's Name.----- --------�� .��. .� - _ Phone _ -__----- - • -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ -Motel ❑ Other ❑ Number of living units: - - Number of bedrooms A Number_of baths _-i2--Lot size __.��__-- -- Water Supply: Public system ommuity system ❑ Private Depth to Water Table ft.i Character of soil to a_depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No t__New Construction: Yes ❑ No Fj-"'THA/VA: Yes❑ No 2}-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspoolpermitted if public sewer is available within 200 feet.) epti nk: Distance from nearest well-----------------Distance from foundation....................Material----------------- ............................... No. of compartments----- .-_.-. - Size___________________ .Liquid depth--- ....................Capacity ispos ield: Distance from nearest well ...............Distance from foundation....................Distance to nearest lot line................. Number of lines----------------------------------- Length of each line------------ -------------Width of french.................................. Type of filter material- -------------------Depth of filter material......_................Total length.........................._......._....... Seepage Distance to nearest well ''Distance frrri ounfion•... ._.___. 'st /ce,to nearest lot line [ Number of pts /l............Lining material ize: Diameter-s- ....._-------Depth....0.2.�- --------- Cesspool: Distance from nearest well___--_ .____Distance from foundation--------------------Lining material---------:........................... , ❑ Size: Diameter._ -___-- Depth-------------------------------------------..._____.Liquid Capacity gals Privy: Distance from nearest well ._._...._----------------------------Distance from nearest building------------------------------------------ Distance _-: _-.__..__ --____:__ -____.-_.Distance to nearest lot line----- -------------- ----------------- ---------•-•-------• Remodeling and/or repairing (describe):-------_----------1,10 ----------------------------- ---------- ---------------------------------------------•----•-•--••-•------•-•- ------------------•----------••- ------------------------------- ------•--•--------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulati. s_of the San Joaquin Local Health District. (Signed)---------------------- -- '' - --- --- ------- ----IQ** Contractor) ?% -- ----------- (Plot plan, showing size of , location of system in,relation to wells, buildings, etc., can be placed on reverse si e FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_------ ----- ---- -•- ----- ----- ------ DATE REVIEWED BY DATE BUILDING PERMIT ISSUED ...................... DATE...... --• •--•-- Alterations and/or recommendations-------------- --.._ ..---------•--••--•- ------•. --•--•-- • -•----••••-•.--•-- I.............. ..................... _----- -•._ ....••-• •-•---•-••---••------ ••------- ---- ------------- -,---2.... 4 ----- - -- ------ ................. ------------------------------- -----I -------------------------------------------------------------- - � -- ... Date . ---- FINAL INSPECTION BY: SAN JOAQUIN LOCAL HEALTH.,AISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North"C" Street Stockton, California Lodi, ifor ie Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO.