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APPLICATION FOR SANITATION PERMIT Permi (Complete in Duplicate) � ( pate Issued .--___/!�$_-- 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 LO ION___------ _ ------------------- Owner's Name ---I---- s-• - - - ------ - :o- z---------•------ ------------- --------- ---------- -- ------- ------ Phone_ Address-- j --- ---------------------------------------- ---- Contractor's Name - -- - --- ' ---•----------------- - -n Installation will serve: Reside Apartment House ----- -----•----- ------------ --------- ----- --- Phone..5----------- ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: ______ umber of bedrooms Number of baths _/__ Lot size � ---- ----- Water Supply: Public system Community system '❑ Private F] Depth to Water Table/-Ie- ft. --------------- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes f No El Construction: Yes F] N f TYPE OF INSTALLATION .AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �l _Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- , �yNa. of compartments ---------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well---- /'-.Distance from foundation_ NIX Distance to nearest loft line__----- Number of lines_________________________ __ Length of each line-----_�'3 Type of filter material .- -- ,� �---------- ----Width of trench------��__.------------_-- Depth of filter material__ _ ------------- Total length ------------------- " Seepage Pit: Distance to nearest well-------------_--------Distance from foundation_.______-______.__-.Distance to nearest lot line-,--------------- F-1 Number of pits----------------------Lining material-----------------------Size. Diameter-- -------------------.Depth----------------•------ --------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------.__ El Size: Diameter--------------------------- ----------Depth---------------------------•------------------------Liquid Capacity-------------------------•- -gals. Privy: Distance from nearest well--------- ________Distance from nearest buildin ❑ Distance to nearest lot linebuilding------------- -- t �mo an ./ ie Z. r repairir '(descc --- -�` -- — _ _i ________________ _______ .. ... - ,l,--- I e eby certify that ordinances, State laws, and ru ---- ilei/an regulations of the San Joaquin Local Health District 4 -(Signed)---------------- ---- - -- • --- - J-------- ------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:-------------------------- Ti+le -_ / (Plot plan, showing size of lot, to tion of system-in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 ' APPLICATION.ACCEPTED BY--(:Z DATE_ REVIEWED BY--------------------------------- -- —'' BUILDING PERMIT ISSiJED---------- ------__ DATE •--------------------------------------------------------------------------------- DATE.------- : - Alterations and/or recommendations--------------------------- ------------------------------ ------------- -- k- __ ---------------------------•- - - -- - -- ----------- - ( ------ --- --- -•-------- �l -------------------'------ '--------------- --------------- 14 ---------- FINAL INSPECTION BY___________ ____'-- _�/ A =---- -------------------- Date_------- �A, --------------------------- 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 .tl Tracy, California ES--9-2M 8-51 Revised W-2100 *�