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APPLICATION FOR SANITATION PERMIT Permit No. � ... �1 (Complete in Duplicate) Date Issued ------y Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Th;s aPplic_atiorr is made in co 11 wit County Ordinance No. 549, l�� OSpJ Z� ,-- described. JOB ADDRESS AND OC TIO _ ~ -_- Owner's Name------ ___ - ---- __ -/XO -- - - ---- - --- - - Address------- Phone- �'i ------------------ Contractor's Name-----" -------------------- OF - - - ;"t;.................... ----------- -- Phone.. Installation will serve: Residence Apartment House ---------- Commercial ❑ Trailer Court ❑ Motel Number of living units: _-/-- Number of bedrooms ❑ Other ❑ - Number of baths gg Water Supply: Public system �+�---- Lot stxe _ Y ❑ .Communit system / Y Y �'�Frivafie ❑ Depth to Water Table i�„�"ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ ClayLoam Previous Application Made: Yes ❑ No - ❑ Clay ❑ Adobe�-lardpan ❑ ) ` New Construction: Yes R?-'No ❑ FHA/VA: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ` Septic Tank: Distance from nearest wefl_;�----tistance rom foundation-" - No. of compartments---" -- ------.Material_.-_&! - /� -- ------ S�ze �` Liquid depth- ! r Disposal Field: Distance from nearest wefle Capacity ----- ------ ---c�+�'--rte--- Distance from foundation_" __--__"_-Distance to nearest lot line------ ` Number of lines___""-""�-_____ _- / —Length of each line Type of filter material-/y ��y Width of trench "r2f�____-_- r� �y------ -- Depth of filter material--- �------.Total length--------- _ Seepage Pit: Distance to nearest well_- pistance from fou ation--"- f p Number of its"--." -" �~ • - is ante to nearest lot line---a- �____ P /-------------Lining materiae Size: Diamefer.�,;„*f-------------Depth_----Zs Cesspool: Distance from nearest well--"_ --------------- Distance from foundation---------------- - Lining material-------------------------------- Privy: -"-_-_"-________- rr__ ❑ Size: Diameter- - --- ------- - ---- V) Depth- --------- -----------------------------Liquid Capacity els. Privy: Distance from nearest well ___ 5 ----------------_-.-----Distance from nearest building p► ❑ Distance to nearest lot fine -"-- 9 w \---------------------------------------- Remodeling and/or repairing describe];-_.__""-_-_-_ ------------------------------------ ' - -------- I -•-------•----------------------- { -----•------ P p pp - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, E (Signed) ------- ---- --- ----- --- - ----- �. - Contractor) (Plat plan, showing size of lot, loc. of system in.relation to wells,--buil----di-ngs- -,--etc-- ----------., can beeplaced on rover ide - ---- ---- - 'FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--_-------_"-------- ------ REVIEWED BY DATE------- -------------------------------- - --- - DATE--- - --- _ _ 1LDWG PERMIT ISSUED --- --------- � ----------- — - DATE- C Alterations and/or recommendations -_-__- """"-_"" - `- ---•--------------------- ----------•-=•-------------------------------- ------------------------ -- -- ---- ----- _ _ -.- ---------- --------- --------- ------------------------------ -------------------------------------------------------------- FINAL INSPECTION Date--7 `"� 0--�j SAN JOAQUIN LOCAL HEALTH DISTRICT !30 South American Street 300 Wast Oak Street Stockton, S - Stooktoa, California Sycamore Street 814 North "C" Street Lodi, California Manteca, California Bracy, California ES-9-2M � Revised 1.57'F.P.CO.