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'APPLICATION FOR SANITATION PERMIT Permit No. __ 4..(._y (Complete in Duplicate) I/ 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 Ordinanc No. 549,. JOBADDRESS AND OCATI ,1 --- --- ------ ----------- ---- - -------------_------------------------------------=------•--------------- Owner's Name----- -- = ------I --- Phone- ----- y 1 i Address -- ----------------------- Contractor's Name - -- -- - �=----------------------- ------ Phone -- --- -------------------------------------------------------- ----------------- Installation will serve: Residence !Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other 0 Number of living units: _ .____ Number of bedrooms__ Number of baths _2__Lot size --___,,2©'! ________________ Water Supply: Public system ❑ Community system ❑ PrivateX Depth to Water Table Y_1$1_'ft. Character of soil to a depth of 3 feet! Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeAv, Hardpan ❑ Previous Application Made: Yes ❑ N,X New Construction: YesA No ❑ FHA/VA: Yes ❑ Nox TYPE OF INSTALLATION AND SPE61FICATIONS: (No septic tank or'cesspool pernvitted if public sewer is available within 200 -feet.) Septic Tank: Distance from neaIest well ----------------- Distance from foundation -------------------- Material -------------------------------------- ---------- No. of 4& compartme'nts-------------------------- Size ---------------------------- ---- Liquid depth--------------- ---------- Capacity ----------------------- Disposal Feld: Distance from nearest wefl------------------ 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 -----------------------Total length ---_---_---------------------------------- ` V Seeps e Pit: Distance to nearest well____7e--_Distance from f ndation__ Q �- ___.Dista i,e to nearest lot iine__� Number of its______ _______________ linin material _ _ ...__ -----_ p � g �"� -__---Size: Diameter Distance from nearest well ----------------- Distance from foundation -------------------- Lining material ------------------------------------- ❑ Size: Diameter ------------------------- ------------- Depth ---------------------------------------------------- Liquid Capacity--------------------- gal Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ____________________________________--- ❑ Distance to nearest lot line ------------------------------------------------ ---------------------- ---------------------------------------------------------------------- Remodelinand/or repairing (describe):___ __. -� ________ ___________________ -----------•---------------------------------------------------------------------------------------------------- N -------------------------------------------------------•---•---• •-•----•-------------• •----------------------- -------------------------------------------------- -- --- 1 I hereby certify that I have rep ed this applicatio and th the work will be done in accordance with San Joaquin County ordinances, S e law , and rule an regulations th an Jo uin Local Heal District. (Signed)--- ----- -- =Y ---- -------------------------(O ner d/or Contractor) By:.------. . .......------------------------------------------------------------(Tit1�__ Y ----- -- ------------------- (Plot plan, showing i ca of system in relation to wells, buildings, etc., can bever side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ------------------------------------------------------------------- DATE ------/- ------- ----------------- REVIEWEDBY =--------------------- -----------------------------------------. DATE ----------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------—------------------------------------- DATE ----------------------------------------- Alterations and/or recommendations: ----------------------------------------•-------------- -- - - - - - - - - - --------- ------------------------------ I_ --•-I—S----------c�r - - -=- -- -------------------------- ------------------------------------------------------------------------------------ -------------------------------------------------- ----- ---- -------------------------------------------------------------------------------------------------------------------------•------- ------------------------------------------- --- ---• -`-------------- -- ---- --- , FINAL INSPECTIO _ --- --- - - ---- - --- ---- ----- ------ Date---- " 5 ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California ES -9--•2M . Revisep 1=5,7 F.P.CO.