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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ----- This _--This Permit Ex ires 1 Year From Date 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. 1, -------------- ' � - JOB ADDRESS AND LOCATION.------- � �--- - - ------•-------------------------------- -- r Owner's Name---- Phone. :. Address---------- Contractor's Name.- • - - • ---------------------------------------------------------------------- Phone •----------------------------- Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � ��p'- �------------------- -------- Number of living units. ___/-ember of bedrooms _ __ Number of baths __1-- Lot size _ - Water Supply. Public system Community system El Private ❑ Depth to Water Table . V Vit. y ; Character of soil to a depth:of 3 feet: Sand ❑ Gravel F] Sandy Loam E] Clay Loam El Clay ❑ Adobe ® Hardpan ❑ ` r Previous Application Made: Yes-❑ ' No New Construction: Yes E] No Z]-'FHA/VA: Yes El No C[� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool'permitted if public sewer is available within 200 feet1) S,ptic jank: Distance from nearest well_________________Distance from foundation-------------------Material------------------------------------------------ No. _-----___-__.__-----_.____________- ----_____No. of compartments--------------------------Size--------------- -----Liquid depth--------------------------Capacity----------------------- 1 �______.-__.Distance to nearest lot line��_.-_______ g ,. ----- ;s 0581 Field: // Distance from nearest well...._`- ___-Distance from fours ti .- -�__ �� Number of lues---_--- ✓------.------------ --Length of each line----�Q--__-__��----.Width of trench.--- ��---------------•-- 4vt Type of filtere aterial_/X - -.:Depth of filter material___._ --�-----Total IEngth___ ____:________________________ ��______._.Di tante to nearest lot line____ .--�- Se 09 Pitt�f Distance to nearest well_____._—__.-____Distance from foundation___•__ __ �. r Number of its' _ Linin material iP4�__Size: Diameter__ -___.Depth..- _______________ p' 9 , N.. � Cess ool: •1 'D-stance from nearest weil_______f' ,Distance from foundation.____.___—_--_=.Lining-material _-..____________________________ Liquid Capacity --------------------------gals. ❑ Size: Diameter---------------------" v Depth -------------------------------------- q P Y 1 Privy: Distance from nearest well-------------------- -----------Distance from nearest building___.-.-__------------------------------- ❑ Distance to nearest lot line------- -----/ - - --- — --------------------------------------------------------------------- v i ------ - - �v W Remodeling and/or repairingdescri e)=--------------•---- ---------- ------------------ -- ----=--------•-----------------------------=`----------------------- - l ---------------------°-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with S'an Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ------------------------------------- - Contractor) , 4 --------------------- g (Piot plan, showing size of lot, locat� of system in-relation to wells, buildings, etc., can be placed on reverse side). FOR DSP 1-RTMENT USE ONLY L--A.-. ------------------- 'I ------------------ APPLICATION ACCEPTED BY.z-- --'rt~-�-��---'-- --- -------- ----------- ------------------------- ------ DATE-----------f-� _'--------- } REVIEWED BY------------------------------------------------------------ -------------------------------------------------- DATE BUILDINGPERMIT ISSUED-------------`-1---------------------- --------------- ----------------I----------------------------- DATE------------------------------------------------------------ Alterations and/or recommeri'dations:---------------------------------------------- •------------ - -----------------------------------------------------------•--------------------- ---- ---- ---------------- ---------------------------•--:..---------------•-------•------------------------------------------•----------- ! ------------------------•----------------------------- --------- ------------------------- ------ ----- -- - --- - FINAL INSPECTIO BY: __. - - �1---- ---- Date--- ----------- -------------------- ----------- SAN JOAQ.UIN LOCAL HEALTH DISTRICT 130 South American Street 300 West 0\,,k`Street 132 Syeamo`e,.S�treet 814 North "C" Street Stockton, California Lodi, Calif mania aS 3 * *' lvlanteee, Califo}nia Tracy, California f ES-9-2M Revised 8-'59 F.p,Co' '