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APPLICATION FOR SANITATION PERMIT Permit No. ice' ........ (Complete in Duplicate) Date Issued Applica-�ion 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 549. JOB ADDRESS AND 96ATION-----'-- --- ---- ------- -- ---- -- ---- Owner's Name. -- - ----------- ---------------------- Phone ,� --7 ✓ . Address_____ _ . . . _. . ._ _ . Contractor's Name -------•------ -----------------•---------------- --------------------------•-- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units:___- Number of bedrooms _-_ Number of baths/..- Lot size _ _ --/ ---_-_-•__-_-..__ Water Supply: Public system [j Community system ❑ Privatee Depth to Water Tab] ft. Character of soil to a depth of 3 feet. Sand Gravel Sand Coam Cla Loam Cla Adob � ❑ ❑ Y ❑ Y ❑ Y ❑ e� Hardpan [] Previous Application Made: Yes ❑ No New Construction:.Yes No E) TYPE OF INSTALLATION AND SPECIFIC TIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �✓ i Septic Tank: —Distance from nearest well------ Distanc from fo�ndation.. Q_...,__-Mater'al____ ------------------- ------------- i No. of compartments.. �------------- -----Size��yeYif�Liquid depth,_�j-------Capacity___--��-_-_ r + � Dis os I Field: Distance from nearest well�D_.....Distance from foundation -___._..Distance to nearest lot I•ne___ Number or` lines______________________ _____Length of each line_____ Width of trench__..__ --------------- �' j� Type of filter material _ -__-.___Depth of filter material____. _---.Total length----------- _ -#`-------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------.------Distance to nearest lot line_._-_---________- ❑ Number of pits----------------------Lining material-----------------------Size; Diameter----------.------------Depth..._.-------------------------- � Cesspool: Distance from nearest well----------------- from foundation...._._.-.-_--..--.Lining material--.._.._---_---_.._.____---___.______ � ❑ Size: Diameter-------------------------- --- ------Depth----------------------------- -------- ---- Liquid Capacity------------•--------------gals: - - - Privy: Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line----- ---- ---------- -------- ---- ------- ----------------------- l ------------- Remodeling nd/or repairing scribe):_ _ . _ ,l4 __._ _ _.4 -__ - ----- w.. ---------- �`�"`' ----= --------------------•-•-------------- ------------ -------------------------------------------------------------- ------•-•-------- -------------------------------------------.•---------------------------- --------------------------------------------------------------- I hereby certify that I have prepared this plication and that the work will be done in accordance with San Joaquin County E ordinances, State I s, and rulgond egulati ns of the San Joaquin Local Health District. i (Signed)----------- --- �� r ------ -----------------------------------------------------_---------------------------- --(Owner and/or Contractor) . B k l Y• �gr � (Tit e}. --- ----------------------- (Plot plan, showing size of , locationiof system in relation to wells, buildings, etc., can be p ed on verse side). �. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- - ---- - ------ - ---- - --------�A------------------------------- -- DATE----------- REVIEWED BY - - ----------------=--------- ----------- ----- DATE BUILDING PERMIT ISSUED--- ------•-------------------------------------------------------------•----- •--------------- DATE---------- Alterations and/or recommendations------------------------- -------- -----------------------------------•------------------ ----------------•-----•-••----------------•-- ----------- -------------------------------------•----------------------------------------- ............. --------------------------------------------- ----------------------------------------------------•--•---------------... ---------------- ------------------ ------ . ..... . -------- ------------------------------..__._.----------------------------•-••--••----------------------------------------------------------- -------- FINAL INSPECTION BY:. -=-^------ -•--------- -- ---------- Date--......_ -,1. -- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California _ Manteca, California Tracy. California !�1 E5-4-2M 145446 ATW30D 12-54 �Y