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g' h7 APPLICATION FOR SANITATION PERMIT Permit No. 0 G� (\/ (Complete in Duplicate) �� Date Issued Application is hereby made to the SanJoaquin Local Health District for a per 't to construct and install the work herein described. his application is made in compliance with Coou/unty Ordin ce No. 549. JOB ADDRESS A O TION-- .-- Com ,. "�_ •............................................... Owner's Na • .. -•-• ----- ------ •----- • --------- Phone- - {- Address -- •---.........................-•--•---------------- ........ ..... ..... ........................ Contractor's Name •.- ,----- - *---------------------------------- --------=........................... Phone _. -._.. ... .. Installation Installation will serve: Residence Apa ent House ❑ Commercial E] Trailer Court ❑�otel ` Other �Q Number of living units: _.(----- Number of bedrooms . c- Number of baths ---I.... Lot size .-_ �. _._{ ....................... ......... Water Supply: Public system EV" Community system ❑ Private ❑ Depth to Water Tabls1e-** ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeg Hardpan 0 Previous Application Made: Yes ❑ NOX New Construction: Yese No ❑ FHA/VA: Yes ❑ NOX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation._....._.............. ....Material -- .___.._..--------------------- No. -..._.-_ _--_-4--.No. of compartments--------------------------Size.................... ._--_...Liquid depth..........................Capacity Disp I F' Id: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-_._--_--..-_.... Number of lines-._-------------------------- ----Length of each line..............................Width of trench ....... JG Type of filter material__ _------------- --Depth of filter material--------- __-_.__ _Total length ---•-- Seep a Pit: Distance to nearest wel -----Distance from f ndati"b istance to nearest lot lin Number of pits- ./--------------Lining material -_ . ---:Size: Dia ter__ a--f---.._._Depth......... �.'_. Cesspool- Distance from nearest well-- ._.._.------Distance from foundation--------------------Lining material------------- ._..._................ ❑ Size: Diameter--------------------------------------Depth----------------- ---------------- --- Liquid Capacity .....gals. Q Orivy: Distance from nearest well --_.-_-__--_ ... . ...... ..... ..Distance from nearest building-__- ................................... ❑ Distance to nearest lot line - . ......... . .... �. Rem eling and/or repa. escribe):-_� * -- - ---- ---• "V -- --- ------ -- -------•---- --------------------------------- .................. ------- ---------w` --------------------------- ---•-•--•----------- --�` - I hereby rtify that I have prepared this apptka#ion and that the work will be done in accordance with San Joaquin County ordinances, to law nd rules gulations of the San Joaquin Local' Health,District. (Signed) -------------------- ------------- ---Ow or Contractor) /� Ti#le By:--------------------------------------- - ------ -- --- ( (Plot plan, showing size of lot, to ion of system in relation to wells, buildings, etc., can be pl edon re rse si FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY..__.-- ........................_................. DATE--____.-__ _ REVIEWED BY .......................... DATE.......... - .......... BUILDING PERMIT ISSUED. BATE Alterations and/or recommendations----------_---- ----- ----- •--- •-----. -------• -- ---------------••-•....---•-- ------. ...-- • ---•--. ------ ----- --------- _ -} ' . .•... .. ••••.. . .. -- -•--------------•-------•-- -- ......--- - -- ----- -• - INAL INSPECTION BY:----- '�---_ / ------ Date.....- {E----- •------ -• --------- -- -- ...--•- -----------•-------• SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C"-Street t Stockton, California Codi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P.CO.