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!APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ---- Application is hereby made to the SaA Joaquin Local Health District for a permit to construct and install the work herein described. application is made in complianc4 with County Ordin6nce No. 549. JOB ADDRESS AND LOCATION_ Owner's Name— ----------------------------------------------------- ---------------- Phone-- - --------------- ---• - Address --------------- Address------------- ------------ ------------------ ------- Contractor's Name--------....... -------;a� ------------------------------------------------------------------------ Phone--------------------- ----------- Installation will serve: Residence [Apartment House E] Commercial [] Trailer Court E] Motel 0 Other ❑ Number of living units: Z.- Number of bedrooms j--- Number of baths --/-- Lot size ___ 'Z-I—-/__Z_IZr-------------------- Water Supply. Public system Er--c;mmun'ify' system El Private E] Depth to Water Table 4�6 ff. Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam n Clay Loam [] Clay Ej Adobe2]---rardpan Ej Previous Application Made: Yes R��o E]'--New Construction: Yes E] No [n-- FHA/VA: Yes F-1 No Zj_---_ TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or'cesspool perWffecl if public sewer is available within 200 feet.) Septic Tank: Distance from nea.resf well---- __---f___Distance from founclafion._,/d---------Materi apacitk_ No. of compartments._.__.-/__ ....size......../�P. -------------- Liquid depth----- C __e52. I Disposal Fiel Disfance from nearest well... --—--------Distance from foundation---Z*W-___.---.Distance to nearest lot lime___ Number of lines------- -------- ......... ength of each line_____- �O-----------Width of trench.___,;2,1V ----________._ T of filter m' �erial_/e__" ' -----Tot I length------- ---------------- Type of filter material a -------- - a �1 /;i- Seepage Pit: Distance to nearest we}l----------------------Distance from foundation--------------------Distance to nearest lot line__.____-___-___-. ❑ ine_------------- El Number of pits-----1----------------Lining material-----------------------Size: Diameter------------------------Depth---------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------.--_Lining material 1771 Size: Diameter_____ --------- ---- -- ---I-- -- Depth----------------------------- ----------------------Liquid Capacity-.--------------------------gals. Privy: Disfance-from ne'rest well-------------------------------------------------Distance from nearest building_______-__.__________________.______-___. ❑ Distance uilding------------------------------------------ Distance to neare'si lot line--------------------------------------------- ------------------------------------------------------------- -------------------- Remodel pai in (cle cr* -------------- and/or re -- - ------------------------------------------------------------------------------------------ ----------------------7--------------------------------6�1 - ------ I - - - -------------_--- --------------------------------------- ------------------------------------------------------------------------------------------ -------------------------------------- - ---------------* - ordinances, I hereby certify that ( have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and, r fes and iegulatiorls of the San Joaquin Local Health District. (Signed) --- --------- -- -- --- -- -- •QWr--Contractor]- - --- - - By:--------------------1........... ----- -------------------------------------(Tifle) ---—----------- (Plot plan, showing size of lot, to n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- - - --- - - -------------- ----------------------- --------------- ----------------------- DATE------- REVIEWEDBY---------------------------------------- . .... ------- -- - ---------------------------------- DATE------- ------------ BUILDING PERMIT ISSUED------------------ - -��T-------------- ----------------- DATE-------------------------------------- Alterations and/or recommendations:_______________ -------------------- -- ------------------------------------------------------------I------------------------------------------- --------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------I- ----- --------------------- ------- --------------------------------------------------- --------------- ---------------------------------------------------------------------------------------------- ----------------------------------------------------- - -----------•-------•--•--------------------------------------------------------------------------------------------------------------------------• ------------------------------------------------------------------------ : j --------------------------------------------------------------I--------- --------------------------------------- ------------------------------------ ---------- ---- --------------------------------------------- II FINAL INSPECTION BY: 6��_ ------------------------------- Date-----_--_-- SAN ate-------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West!Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California P Lodi, California Manteca, California Tracy, California ES-9-2M • Rev;sea 1-57 F.P,CO.