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APPLICATION FOR SANITATION PERMIT Permit No. ___..... (Complete in Duplicate) 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. �/ (o - ------------------------------------------ JOB ADDRESS AND OC ION-------- ------------- --------------------------------------- ----------------------------------------------------- d - --- --------------------------- ------------ ---- Owner's Name �.J----- ,------ - -- Phonec�__r� --- Address- --------- ------- ----- -- ------------- ----------------------------------------------------------------- --------------- Contractor's Name f ------- -- _ ... ----------------------------------------------- Phone � __51 . Installation will serve: Residence Apartment House ❑ Commercial E]Trailer Court E] Motel E] Other El,___-_ Nu Number of living units: mber of bedrooms___ Number of baths __. Lot size _= ............... Water Supply: Public systemCommunity system [I Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0C lay E] Adobe Hardpan F]w, , k Previous Application Made: Yes E] No New .Constructian: Yes ❑ No,X FHA/VA: Yes ❑ N� TYPE OF INSTALLATION AND SPECIFICATIONS: { (No ,septic tank or' cesspool permitted if ublic sewer is available within 200 feet.) Septic Tank: Distance from nearest well_____.________ Distance from foundation-__f1i--- �---- Materl__- T�____ ________(_`�__ -_---. No. of compartments Size___a_�.' y____._Ca acit 3_-_.________ [�� P ra�. �X Liquid depth- ------ p Y Disposal Field: Distance from nearest well?10K9,-from foundation ---- 140___�____Distance to nearest lot line__________ LE]/ Number of lines____________________ Length of,each line ----- -TV-- ____`f ----- Width offrench ____v�_51____________-______-- Type or` filter material sr__JV Depth of filter material ---- Toial length_________• ' _________________________ Seepage Pit: Distance to nearest well�rr�� Distance -f m f unciation______Z_ _____.Distance to nearest lot line____��_,__ Number of its_______ __ Linin material__ f ;_.Size: Diameter___--��______- Depth____O____0 -------------- - j 9 1:9 `V _. _. -- _ - Cesspool: Distance from nearest well_____________ Distance from foundation.."....- Lining material_____________________________________ Size: Diameter-------------------------------------- Deth_________________ Liquid Capacity gals. --- - ----- - - - Privy: Distance ,from nearest vrell____��_ __________________________Distance from; eareit building ------------------------------------------ El Distance to nearest lot line------------------------------------------- --------- -------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------ -------------- ----------- -------------------------------------------••--•--•----- -------------------- ------------------------------------� ------------------ --------------------------------------------------- --------------------------••---------------------------------------- -------------------------------------------- t -------- I-------------------------------------------- --------------------•------------------•--------------------------- -------------------------- I hereby certify that I havel'prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St s, and rules and regulations of fhe San Joaquin Local Health District. (Sign) •.--------J-------------------------------------- ed�Owner and/or Contractor) er----------------- [ ' J ------------------•------------------------ (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.,B------------L,DATE.�_-•--•-----•-------•--------------------------•---- BY----------------------------------------------- DATE---�------------------------------------- - ------------ REVIEWEDBUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------------------ DATE------- �--------------------------------------------- Aleratins and/or 4o men aio - ---!-"•-------------------------•--•-----•------------------------- sf coq .�w -------------------1----'------•-----•----------------•-----------------------------------f -------- I ------------------------- ---------------------------------------------------------------- --------------------------------------------------•------------------------------------------------- --------•--------------------------------------------------------------------•-----------------------------•------------ V. FINAL INSPECTION -,BY---------------- r - --------- --------------------- Date ---1 � 1 =1 -7--------------------------------------- ISAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Ainerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M , Revisea 1-57 FRCO.