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APPLICATION FOR SANITATION PERMIT Permit No.s^.�.------_-_ (Complete in Duplicate) Date Issue/� �r1 I 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 i JOB ADDRESS A CATION - =t�? ------------------------•---------•--------------- ---- -------------------- Owner's Namey •------- ---- -- -- ----------------------------------------- Phone- �- -------- Address-------- ---------- -��--------- -- --------------------------------------------------- ---Z---------------------- !. Contractor's Name--------------- - -------- "`-------�---------------------------- Phan , - •� 4 Installation will serve: Resi ence J�' Apartment House ❑� Commercial ❑ Trailer Court ❑ Motel Ot r ❑ Number of living units: -- ----- Number of bedrooms,_ Number of baths --/__ Lot size ------- -----_ r ------------------------ Water e' -- '.__-___Water Supply: Public system ❑ Community system ❑ Private)< Depth to Water Table,--eU ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob� Hardpan ❑ Previous Application Made: Yes ❑ NX New Construction. Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , r `(No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic Ta k: Distance from nearest well___..._________Distance from foundation--------------------Material------------------------------------------------- No. of compartmems- -----------Size-------------------------- ---Liquid depth--------------------------Capacity--------------- ---- Disposal Fie}d: Distance from nearest well--- ._Distance from foundation--------_-----------Distance to nearest lot line_______._____.__. d Number oz lines----------------------------------Length of each line-__---------------------------Width of french-------------------------------- Type of'filter material-------------------------Depth of filter material-----------------------Total length________________________________.____-.-. � � r Seepage Pit: Distance to nearest weII�Q_________Distance from f undatian��,____:_- Distance to nearest lot line__.___ _ _ ��g..� , Number of pits.----I--------------Lining material Size: Diameter-----�--------Depth------ -------------__-- Cesspool: . Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- Fj Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------_------_-------------------------------Distance from nearest building-----------------------_________..._. ' ❑ Distance to nearest lot line_____________ '" . ,/ V , - Re od ing a /or repair'n.g (describe):-- --------- --------- /o - ---- ---- ^---- -- i -- --- ---------- ----- -- `------------- - - ------- {--� --- --- - -------------------------------------------•--•-------------- -------------------------------------------------------------------------------- ------------------------------------ re c r+ify that I have prepared +his appl cation and that the work will be done in accordance with San Joaquin C my ordinances, St laws, a r s and reg tions of the San Joaquin Local Health District. (Signed)---- ---- � P-- - - -------------- ------------------------ ---------------------------------------------------- (Owner an_ r Contractor) -------------- By:.......... Y l��.. - -------------------------------------------•------------------------------------------(Title __ . �`"�` ----- (Plot plan, showing size of lot, location of system in relation to wells,.buildings, etc., can be d on rever side FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------- /; ----------- DATE---------•-•- r V -&-=-- .�.:_ - REVIEWEDBY-------------------------------------------------------------------------------------------------------=----------- -- ----- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED--------- ------ DATE.-,-�----- ° F Alterations and/or recomm ndations '` _--S`, ._ 'r - 'Gi-- -----------------= " : =m- �p-------- --------------------------------- ----- ------------------- - --------------------- ------------------------------------------------------- --------------------------•------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:---------- - _ " - -•---------------- Date-------------- •- ------------------•------------------ SAN -- -•---.- .._.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-4--2M 10-52 Revised W-2104, "