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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued _$L�_�_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 LOCATION_ -- L J , 1 Owner's Phone ------- - -yam' Address------- _/_._44y---------_------�=--------- ------------------------------- Contractor's Name Phone --- ---- - -- - ------------------------ ------------------------------------------- - - --- -- - - --------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other E]Number of living units: �_____ Number of bedrooms Number of baths __�___ Lot size ____ ___Gt'_____________ ----------------- --------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [New Construction: Yes No ❑ FHA/VA: Yes ❑ No pe_00,r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fe t.) ➢ Septic T Distance from nearest well --G /-- Distance from rfound�,tion 7�---.Mat fiat �� - - -------- -------------- 20 No. of compartments ------ ire- _______Size____ _ . _ -.:5-�--�----Liquid depth---�----------------- CapaatY-----��--. i 00 Disposal d: Distance from nearest well .� (�---- Distance from foundation;_/ C `______-Distance to nearest lot line_ -------- Number of lines__Z��f Length of each line ------ Width of trent -_ .rt%�' Type of filter materiallX,cZ�_Y{"` Depth of filter material f Total len th._ A� ---- - 9 b�� --•-•--------------------- Seepage Pit: Distance to nearest well ------- _-------------- Distance from foundation -------------------- Distance to nearest lot line_________________ ❑ Number of Pits -------------- ------- Lining material ---------------------- Size: Diameter---------------------Depth--------------------------------- 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 to nearest lot line-- ---------------------------------------- ------------------------------------- --------------------------------------------------------- Remodeiing and/or repairing (describe):------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be' done in accordance with San Joaquin County ordinances, Stag• laws, and rules and regulations of the San Joaquin Local Health District. -- -------- -- --------- ---- --- ---______ _ - _____(Owner and/or Contractor By:-------------------------------- -------------- - Tale _______ _________ __ _) -- - - - ---------------- ------ - ------------- - (Plot plan, showing 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 BY - - ----- ----------------------------------------------------------- DATE---- J.5 ------------------------------------ BUILDING PERMIT ISSUED------------------------ ---------------------------------------------- DATE------ ------------- - -- - --- ------------- Alterations and/or recommendations:______. �i/ Date ----- FINAL INSPECTION BY:.. �f ---------- ---- tt 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 , Revisea 1.57 F.P.CO.