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APPLICATION FOR SANITATION PERMIT Permit No. -- Z (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. 49. -:L;Q h JOB ADDRESS AND OCATION_ ..�✓ ------------- - ---------- Owner s Name ��'� -------------- Phone------------------------------------ Address - -----------•- ----------- - -- - ------------- Contractor's Name------•.- ------ Phone------- ------_------------------- -- -(]--------------- I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer -Court ❑ Motel ❑ Other / __ Lot size - -� Number of living units: ________ Number of bedrooms _ -- Number of baths _ (- Water Supply: Public system Commuriity system ❑ Private ❑ Depth to Water Table _______ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No FHA/VA: Yes ❑ No TYPE OF INSTALLATION tank orAND SPECIFICATIONS: PALLATlO,.i cesspool permitted if public sewer is available within 200 feet.) � No se ,, -'�-•��,,,, 44 444?--------Material__ �� Septic Tank: Distance from nearest well . T Distance from of compartments--- __Size__ _- --- 0.Liquid dept-------�----------Capauty ---. - -• Disposalield: Distance from nearest well_' istance from foundation__/ .___---Distance to nearest lot lin4��-------. Number of lines--------- --------------------- ength of each line_---- eQ ------.Width of trench----- ---- ------------------ �� ----Total length-•----�P--------------- Type of filter matenal_l�_ __.__Depth of filter ma#enal___��._____ 4.0�___-.Dist a�r ce to nearest lot line__9.. �V Seepage Pit: Distance to nearest well-7 f-4-Distance from foun tion___ _ ize: Diameter-. --- -----.Depth Number of pits___.__------------Lining materia/0, - Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material__.___-_.---__.______--___________:__ ❑ -------Depth----------------------------- ---Liquid Capacity------------•---------------gals. r Size: Diameter_ --------�-- ----------- -- -- ---------- - W Privy: Distance from nearest well __ ---------------------------------------------Distance from nearest building-----------.-------_-------------------- ❑ Distance to nearest lot line --------- ----- ---- ----------- -------•------------------------- -- -- -- - ------------------------------ - -------------------- ------- rr - - --•------------------------------ - Remodeling and/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 i ordinances, State laws, and rules and reguia ions of the San Joaquin Local ealth Distri t. Contractor] (Signed)'---. - -------------- ------(Title]_- ----- _ BY� ---------------------•- ------- .: [Plot plan, showing size of lot, 1 ion of system in relation to wells, buildings, etc., can be place n revers ide]. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------ - ------- ---------------------------------------------------- -------------------- DATE------- ---- -------------------------------- REVIEWED BY-------------=------------------------------ ------------ --- --- - ------------------- ----------------------- --- DATE------ BUILDING PERMIT ISSUED---------- – DATE ------ -------------------------------------- Alterations and/or recommendations:__-___________ _--- ----------------------- ------------- -------- ------------------------ V ------------------------------------------------- ------------------------------------------ ----- Ii -------- Date--------- ------�-f---- — _'l------------------------------- FINAL INSPECTION BY:------- l SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C' Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y, ES-9-2M , Revised 1.57 F.P.CO.