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APPLICATION FOR SANITATION PERMIT Permit No. .. (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made'to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. S49. JOB ADDRESS AND LOCAT ON__� / ` •_u_ -------------------------------- _ --_- -_L -1- Owner's Name 7 --- -�----------------- -- ---------- ------------------------------------ Address oC� i -4-------------------------------------------------- Phone Address-------------------- r..� - l ------------------------------------------- Phone----------------------------------- s Contractor's Name..--- Installation ame.Installation will serve: Residence P�--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ____ Number of bedrooms ,_ Number of baths __j____ Lot size --------- -s�_�________________-_----____ I Water Supply: Public system ❑ Community system ❑ Private 2r'5epth to Water Table _,q-a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ AdobeEr--H-ardpan ❑ Previous Application Made: Yes ❑ No,Z"'New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No [�}� 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. of compartments------------------=------Size-------------------------------Liquid depth--------------- ------- -Capacity-----------------------1 1. I Dijposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line________-_-______ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench-------------- ------ { LLLTTT Type of fitter materia--------------------------Depth of filter material----.-----------------Total length------------------------------------------ W1 i , Se page Pit: Distance to nearest well_--------------------Distance from foundation--------------------Distance to nearest lot line-----.____-..-.-. rs Number of pits-------i--------------Lining material-----------------------Size: Diameter----------.------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__._____---__------..________________ ❑ Size: Diameter------------------------------------Depth---------------------------------------------- Liquid Capacity---------------------------gals. fi Privy: Distance from nearest'well ________________________________---.-----------Distance from nearest building-------______________---_- f ❑ Distance to nearest lot line---------------------------------------------------------- -----------------------------------------------------------•-------------------- Remodeling and/or repairing --- ----------------------------------------------- 1 fr- -- ----------------------------- ------------------------------- ------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District, f i (Signed).__ _________________(Owner and/or Contractor) + By:--------- ----- --- ---------- -----••--------------------------------------------------------------•-------------- -----__-(Title)------------------- -------------------------------------- -(Plot plan, showing size of lot, I cation of system in relation to-wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- 't-- ------------- ---------------------------------------------- DATE--- --------- REVIEWED i3Y_ ----------------------------------------------------------- ---------------------------------------------- DATE------- i BUILDING PERMIT 'ISSUED----------------------------------------------------------------------------------------------------- DATE :. Alterations and/or recommendations______________________----- ------------------------------------------------------------------------------------ - ------------------------------------- -----•------------------------------------------------------------------ ,I ---------------------------------- ------ ------- 3 FINAL INSPECTION BY:. Date. ------ SAN JOA UIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C"Street f Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 6-'59 P.P.Co.