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APPLICATION FOR SANITATION PERMIT Permit No. ..... (Complete in Duplicate) Date issued ---7N7 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 Cc my rdinance No. 549. --.. Phone ------------------------------ Owner's - - JOB ADDRESS AND O ATION_• ----�' - ---- --- ------------------------- - Owner's Name---- ------ ---- - - ----------------------------------------------------- ---------- Address------ - --- -- - ----- -�-- ` - -- -`-- -------------------------- --------- h ---• d .Contractor's Name--------• -- -- ----------=-• - ------ -------------•-----------•-------- Pone.---------..---------------•-----•- ' ❑ Installation will serve: Residence Apartment House Commercial. ❑ Trailer Court ❑ Motel ❑ Other ❑ i -------------------------- ` __ Number of baths _ Lot size :_Apoly-' Number of living units: __-.-.__ Number of bedrooms Water Supply: Public system ❑ Community system �rivate ❑ Depth to Water Table ft: Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A-<ardpan ❑ Previous Application Made: Yes ❑ No P�New Construction: Yes �lo ❑ FHA/VA: Yes 0 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: .„ (No septic tank or`cesspool permitted if ublic sewer is available within 200 feet.) Septic Tank: Distance from nearest well _ -__ _Distance from foundation--. Materi�1--- No. of compartments'.. Capacity---- No. ry Size __ - Liquid depth p y---- i Distance to nearest lot line_- --- , Disposal Field: Distance from nearest welllr.�rX_-A 'Distance from foundation_ Len th of each line- Width of french-------------------- �/ Number of lines----- a-----f----- 9f -- Type of filter material..-' -Depth.of,•filter material--./o -_Total length.-_-,�,�----------------- Seepage Pit: Distance to"'nearest yell-- Distance -from fou ation---�l�--------.Dista e to nearest lot line--/_re------- X. -r-- . '- i Number of`.pits------_--_--_____r-Lining mater al� Size: Diameter-_- -__---_Depth_----01441------------------ k Cesspool: Distance from nearest'wel-----------------Distance from foundation ------ ------ ---Lining material-------------------------------------- Cesspool: _- ._---_-. -_-.--_-- a gals. ❑ Size:•Diamete ----------------------- - Depth---------------------------------------y4 -----------Liquid Capacity -------------- Privy: Distance from nearest well -- __ Distance from nearest building------------------------------------ Distance --_ ----- ------------------ --Distance to nearest lot line------------------ _ ----- -- ---------------------------------- Remodeling and/or repairing (describe):------------ -- ---- --- - ---------- --------�---- - _ --------------- - - ----x-----------------'----------------•-------------------------------- t 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ounty ordinances. State laws, and rules and r ulations of the San Joaqui Local Health District. '' Contractor] ( -J (Signed) ---- - --------- ----- - By:........................................... ------------ ------------------------------------------(Tifl - - . e)_ (Plot plan, showing size of lot, lo c n of system.in'relation to wells, buildings, etc., can be placed on revers ide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- - -------------- DATE------- -------- BY------------- ----- - ---------------------------- DATEDATE a ------ (: BUILDING PERMIT ISSUED-------------_---------------.-_- --- ---------- - ---------------`� T` ' ------------------------------ REVIEWED ------ ---- Alterations and/or recommendations:--__--__._---_-_--__.- - :-0 "' r- -------- -- ------ -- -- •--- 4 -------- --- --- ------------------------I.. -------- ------------------------------------------------- ------------------------- ----------------------------- FINAL ------ FINAL INSPECTION BY: - = -------------------------- Date-- 7- -- -�" SAN JOAQUIN LOCAL HEALTH DISTRICT 130 SouthAmericanStreet 300 West Oak Street 132 Sycamore Street . 814 North "C" Street 1Lodi, California Manteca, California Tracy, California Stockton, California a, ES-9-2M Revised 1.57 F.P.CO.