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APPLICATION FOR SANITATION PERMIT Permit No. __ -- �i" (Complete in Duplicate) Date Issued 3J-f4-W 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 NoAg 0" . 549. .� JOB ADDRESS AND LOCATION--_----- -------- Owner s Name______ __ - -- Address •= fie► _ � , -----�- ------------------------------------------------------------•--------------•-------------------------- `•f Phone----------------------------------- Contractor's Name Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer;-Court ❑ Motel ❑ Other ❑ Number of living units: .„__ Number of bedrooms __ Number of baths __ Lot size ___r ` _ -! -------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8�Hardpan ❑ { Previous Application Made: Yes ❑ No UR"'New Construction: Yes ❑ No P!I' FHA/VA: Yes ❑ No [�J— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Tank No. Distance from nearest well_________________Distance from foundation__._----------------Material--- ____.________.___________...____.-_______.. No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disp al Field: Distance from nearest well_________________Distance from foundation------------------ to nearest lot line----------------- ' Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- - Type of filter material-------------------------Depth of filter material---------------- ------Total length--------------------------------------- Seepage it: Distance to nearest well__-"'r�--------Distance fTm f-o-un�ation__� --_______.Distance to nearest lot line__P Number of pits---/--------------Lining materialrz ize: Diameter_ 4� �_-----Depth___ ------------------- Cesspool: Distance from nearest well--------------___Distance from foundation------------._____.Lining material------------------------------- a-- ❑ .Liquid Capacity------------•--------------- {� Size: Diameter------- - ------------ -----------Depth---- -----------------------�---------------- g l Privy: Distance from nearest well----'--------------------------------------------Distance from nearesf building---------------------------------------_-- ❑ Distance to nearest lot line-- --------------- ----------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------ ----------------------------------- •---------••-------- L;-- � j- ----••--------------- ------ -------------------------------------------------------------- ----- - -------- - -- ------------------------------•------------------------------------------------------ -----------------------•-------------------------------•------------ •------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. „F. � . r Contractor) (Signed)_._ = -----Ile '' ---- -- Sy:---------------------------=-------------- -01 ------------------------------------[Title)-- i showing size of lot, locat' of system in relation to wells, buildings, etc., can be placed on reverse d (Plot plan, g_ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -------------------------------------------------------------- --- DATE -------------------------------------------- REVIEWEDBY DATE-- --•--------------------------------------------- BUILDING PERMIT ISSUED-------------- -------- -------- DATE t^ BUILDING and/or recommendations:------- --------- ------------------------------•-----------------•----•...-----------•--•--------•---------------- ----------------------------------------------------•------------------------- ---------------------------- --------------------------------•--------•-------•----- -�----•- -------------- -----------------•----------------------------------------------------------------------------------------------------------- .� 1- FINAL:. INSPECTION BY: pf. Date----- 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 Tracy, ,CaliFarnia ES--9-2M Revised 1-57 F.P-M