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PPLICATION FOR SANITATION PERMIT Permit No." . (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 Ordinance No. S49, JOB ADDRESS AND OCATION---.,3 -- r -------------- ------------ ------------------ ---------_-__ Owner's Name-------- �---- ----- ! ---- -- Phone---- ------------------------------- Address---...-----------------•-----�Z� rty� t.------------------------ Contractor's Name------•------- ------- -------------------------------- -------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E]may, . � Number of living units: _L� unity Nu er of bedrooms .-2,.- Number of baths _ _____ Lot size �� _________________________ Water Supply: Public system system ❑ Private ❑ Depth to Wafer Table --------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe�ardpan El Previous Application Made: Yes E] No �w Construction: Yes U-- ❑ FHA/VA: Yes ❑ No�� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest well*�'�-. _Distan e from foundation_-_1� ____..Material__._ __ _ ___________ No. of compartments-------____--.-.--Size--- _ __ .._..._Li ui de th---- � __Ca acitQd G p y p 4107W_.-Distance from foundation_ . Dis osal geld: Distance from nearest weft_ ,� Distance to nearest lot line....._�___ ___. Number of lines------;2-----------_---__ + � Length of each line----__-___._ Width of trench--- y`F__----- ----------- Type of filter material__---- _ Depth of filter material___ __ __lf______Total length_-__- Seepage Pit: Distance to nearest well--------------- --Distance from foundation--------------------Distance to nearest lot line__---._---------_ rr - ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------.------Depth--------------------------------- W Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.--__---___.---_-_------__-_-___-. Q ❑ Size: Diameter------------------------ ------Depth---------------------------------------------------Liquid Capacity----------------------------gals. : Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------__---------- -._. ❑ Distance to nearest lot line----------------- -- ------------------------ - -------------------------------------------------------------------------------- Remodelingand/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- -------------------------=---------------------------------•-------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -- ----------------------------------- -------••--------------------------------------------------------------------------------------------- --•------------------------------------------------------- ----------- - 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 r 6sregulalio s he San Joaquin Local Health District. \f �- (Signed) ----------- -- --- ---------------- ------- ---------- - - -- -------- --- -- Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------•-------- DATE REVIEWED BY-------- - ------------- DATE------------------------ - -- ------------- BUILDING PERMIT ISSUED------------- ------- ------- ------------------------------------------- ---------------- DATE-- --- Alterations and/or recommendations-------- =----- ------ -------------------------------------------------- -----------------------------------------------------------•-•-----•----------------------------------------------.._._...-------------------------------------- - -------------------•-.-_..-------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- FINAL INSPECTION BY:-- 4 -t,-`-'------------------------------------ Date.-- � -----9. ----------------------------------------- ----- -- 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-9-2M , Revised 1-57 F.P CO.