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APPLICATION FOR SANITATION PERMIT Permit No. __• _ _ __.... # �} (Complete in Duplicate) T t� I Date Issued 1- ! Application is hereby made to the San Joaquin Local Health District f a permit to construct and installeworrein described. Thisapplication is made in compliance with County Ordinance No. JOB ADDRESS AND C IONt � ----- } Owner's N r tom_---- --- ------------------------------------- Phone.-- . J Address - -----=-----•---- •----------- ----------------------------------------------- Contractor's Name..---------- . ---�----------- ------ -------------••------ Phone. _ Installation will serve: Residence. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: --1---- Number of bedrooms _Z_ Number of baths /--- Lot size __-- Water Supply: Public system ommuriity system ❑ Private ❑ Depth to Water Table =ff. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobelardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic,tank or'cesspool permitted if ublic sewer is available within 200 feet.) ' Septic 7a Disfance from-nearest well-- ®-] _Distance from oun afion._ _�_.____M r I _- No. of com artments_____ Size t p ___r_____Capacity.:.. p Liquid de th--- e Disposal Field: Distance from nears t well_-K� Distance rem foundation---2—�*Distance to nearest lot line___.,�_0_--0, � Number of lines ------- _______ _A Length of each line__�La___---t------,Width of trench__ /___ ..___.___ Type of filter material_ - a Depth of filter material---/_ ---rI__Total length-- ---_---------------` Seepage Distance to nearest well___ _ _ -__Distance rem oundation_&_. _Distance tp nearest lot Number of pits---t_---------------Lining materiaL-�___.__.Size: iameter______- - --� Depth_„ _ q Cesspool: Distance .from nearest well_______ _________Distance from oundation-------------------.Lining material-------------------------------------- El Siz,e: Diameter------------------ -----,---------------De th------------------------------ ------- -------.-_-Liquid Capacity----------------------------gals. y Privy: Distance from nearest well----------_------------------------______________Distance from nearesf'building------------------------------.__-_____-- ❑ Distance to?nearest lot line------------------------------- - t Remodelingand/or repairing (describe):-----------------------------------------------------------------------------.---------------------------------------------------------------------------- ------------------------------ --------------------- - -------•---------------------•------------------------------- ? I hereb certify that I ave prepared tjn+lsonpof ation and fhAna zwi--�e done in accordance with San Joaquin County € ordinances, S to laws, and rules and regulthe San Joaealth District. (Signed) - ------- -------------------- ------------- 1�df�r.Oohtractor) By. ------------------- ---------- tie ---- ---=•--------- --- -(Plot plan, shows .g size of lot, location of system in.relafion to eetc., n be placed on reverse side). FOR DEPART NT USE ONLY APPLICATION ACCEPTED BY- - --------------------------------------------------------------------------------------- DATE-- y REVIEWEDBY----------------------------------- ----------------=----------------------------------------•-------------------- DATE--- ----------------- BUILDING PERMIT ISSUED-------------------------------------------------- ----------------------------------- DATE----- ---------------------------------------------- - -- ------ - - Aiterafions a recommendations:------------ ----------------------------------- e----- ---------------------- -------------------------�j--------- - ------------------- ------- ------- -�-----------------------------------•---------------------......--------------------------------------- -------•-------------- -----------------------------------------------=--------------------------------------------------------------- -------------------------------------------------------------------------------------- , - -- FINAL INSPECTION' BY-------------- --- --- --------- ------- Date----- f ti x °r 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-9-21x1 , 1Revisea 1•57 F.P.CO. s