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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 incompliance with County Ourdi, n e No. 549 JOB ADDRESS AND k�L�9,)CN___ ------ ------------------------------------------ ----------------- ........ ---------- ---- ------ ..... . . ...... Owner's Name----- ........................ ---------------------------- ------- ------ Phone.------- --------------------------- Address------- - ------------------------- ----------- ---- Contractor's Name------------- ------- ----- � Phone ----------------------------- -----------_--------------------- - Installation will serve. Residence �Apartment House E] Commercial 0 Trailer Court Ej Motel [:j Other ❑ Number of living units: J---- Number of bedrooms _q... Number of baths ---/__ Lot size --- __________________________ Water Supply: Public system gro"Community system El Private F-I Depth to Wafer Table'47ft. Character of soil to a depth of 3 feet. Sand El Gravel E] Sandy Loam E] Clay Loam 0 Clay E] Adobe �j�ardpan 0 Previous Application Made: Yes E] No &0"*New Construction: Yes 0 No �HA/VA: Yes 0 No LiM— TYPEOF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Se.ptic Tank: Distance from nearest well_0X4-'._Distance f rom foundafion__/�-------Material---&--4_044;9;;�.Z-------- *. gr ~ No. of compartments___-------------------Size--- Liquid depth_____ ........Capacity---- Disposal Field: Distance from nearest well_ Distance from foundation.__e (f______-Distance to nearest )of line_________--. Number ine-_7------- Number of lines___.________.__ _ - Length of eachline_____---_--_------ Width of trench----- -- ---- ----------- Type of filter..material__1 __of6ek.-.0 Depth of filter mate ria _______Total length------4-:p 49 11---------------------- Seepage Pit: Distance to nearesf-well__',�, _ �__Disfance from foundation----144.........Distance to nearest lo-61ine-- Number of pifs_"__/------------Lining �nateria/_,i&ov&_.Size: Diameter__ -----------Dept h----a-Q'-___________- a Cesspool: 9----------------- Cesspool: Distance from :nearest well______.____._,.__Distance from foundation--------------------Lining material_____._______._____________________- \�l ❑ Size: aterial-------------------------------------- Size: Diameter----------- -------------------------Depth------ ----------------------- ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__________._______________________.____._- Q ❑ Distance uifding------------------------------------------ Distance to nearest lot line_----__--------- ----------------------- ------------------------------------------------------------------------------------------------------- Remodeling and/oribe)---------- --- repairing (describe)---------- "o- --- ,�__ - - ------------------------------------------------------------ ------------------------------------I---------------------------------------------------------------------------4------4----------------------------------------------------------------------------------------------------- ---------------------------------------------------------I----------------- -------------------------------------------------------------------:------------------------------------------------------------------ ---------------------------------------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ' 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 Dis+ricf. --- --- -- --------- --------------------- (Signed)----------- By:------------------------r--- --------------- - -- --- - ----- ------------------- -----------------------------------(Title)------- (Plot plan, showing size ofolocation of system in relation to wells, buildings, etc., can be placed on reverse sid FOR DEPARTMENT USE ONLY ----------- APPLICATION ACCEPTED BY--------------------------- - ---- ------------------------------------------------------ DATE-------:3;?------------------------- --------------------- REVIEWEDBY--•---------------------------------------------------------- ------------------------------------------------------------ DATE------------ ------------- ------------------------ BUILDING PERMIT ISSUED---------------------------------- ------ ----------------------------------------------------- DATE------------- - ----- - ------ - -------------------- - ---- ------------------------------------------- -------------- ---------- . .... . ..... Alterations and/or recommendations:-------------------------- - ---- --------------------- ............ . ----------------------------------------------- --r------- ------- ------- ------------- --- ------------------------------------ ------- 0---- ---or -- ---- -- ------ ------ -- --------- --------------------- ------------------------------------ ---------------------------------------------------------------- --------------------I- -------- - ----- -------- _ 77 -- -------- __-4 ' --------------k-- ----- ------- ------- - -- ---- ------------------------------------ --------------------------- -------------------------------------------------- --------------------------------------------------------- --------------------------------- FINAL INSPECTION BY:_ .......................... -------------------------------- 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, California ES-9-2K4 Revised 1-57 F,P-co.