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APPLICATION FOR SANITATION PERMIT Permit No, .__ __a. � 4 AR (Complete in Duplicate) 3 i Date•issued ._/�I.S_7__ 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 Owner's Name_ ----...'--`----------------------------------------------------------- Phone- Address / -------- --------- - --------------- Contractor's Name----------------- ---------- - -- ------- -----------------------------=--------•---- Phone, -.0 4 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J__ Number of bedrooms Number of baths _/-___ Lot size ----74— - ______________ Water Supply: Public system ❑ Corrmniun'ity system ❑ Private �epth to Water Table 4 ft. Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-Hardpan ❑ Previous Application Made: Yes ❑ No [l�New Construction: Yes ❑ No [t�FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available.within 200 feet.) pti Tank: Distance from .nearest well-----------------Distance from foundation_--______--.--------Material---------------.__----- _-______--..-_________- No. of compartments------------------------ Size------------------=------------Liquid depth------------- ------------Capacity---------------------- S --------------- ` spo eld: Distance from nearest well-----------------Distance.from foundation--------------------Distance to nearest lot line---_.--___-____-_ Number of lines-----=----------------------------Length of each line------------------------------Width of trench---------------------------------- Type of filter material_________________________Depth of filter material----------------------- • well _ ' lengt.h___._--_____________-_- ___-_-._i-_- _._._._ See a Distance to nearest wefll _____.______Distenc om foundation--- iad---------Distance to nearest lot line_c?Q- Number of pits---_./-----------Lining mat __-Size: Dieter_.0-- ---------Depth...... R ------------------ Cesspoof: Distance from nearest well-----------------Distance from foundation-------------------.Lining material___---------------------------------- . 9 ❑ Size: Diameter--------------------------------------Dept h----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------ --- _--- ❑ Distance to nearest lot line----------------------------- ---------------------------------------- Remodeling 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, St Paws, and rules and regulations of the San Joaquin Local Health District. (Sine(j ---- ----- ------- ------------- 9 �------- ---- • -------------- - ------;------L- ---- --------•-------�_ (00wner and/or Cortractor�BY:------------------------------------------------------------- � �/ -. Title ------------------------------------------ - - -- (Title) (Plot plan, showing size of lot, location of system in relation to wells, build' gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- -------------- DATE--- A:+ . --•---------------------------.-. y REVIEWED BY------------------------------------------------------------- -- - -------------------------------------------------------- DATE------------- --/----.------- BUILDING PERMIT ISSUED------------------------------------- ----- -- -- DATE-----_-__-- Alterations and/or recommendations---------------- --- ' •--------------------------- 8:4 --- -- ------ ti --: - -------------------- ------------------------------------------------------- ------------------------------------------------------ ------- , --------------------------------------------------------- FINAL INSPECTION BY:--- --5------------------------------------- Date--- -1------------- SAN ----SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak $free+ 132 Sycamore Street 814 North "C" Street Stocktonr California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CO.