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APPLICATION FOR SANITATION PERMIT Permit No. Pu-0-61-------- _(Com(Complete plete in Duplicate) Date Issued,?/-- Application ssued/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 witb. ounty,.Ordirlance,No._S49v- JOB ADDRESS A LO TION-------- r� Owner's Name------ 1 1------------ _- - -- - - -- -------------------------------------------------- ------ Phone-------------------••--------------- Address----------------------- �✓: Contractor's Name -*• - ----------•----------------------------------------- ---------------------- Phone i Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1-_ Number of bedrooms 3-_-- Number of baths --/--- Lot size .__- _-_-----_-- ---- __---_----_---------_ Water Supply: Public..system' ❑ Community system ❑ Private Depth to Water Table ---------it. Character of soil to a depth 04.3.feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--nardpan ❑ PreviouS Application Made: Yes ❑ No �w Construction: YesNo ❑ FHA/VA: Yes ❑ No Ifs Y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) „ .01 -------Material-- -------------- Septic T Distance from nearest well--�-_-------Distance from foundation__-:--- - ------- Nn. of com artments---- -Size-_-- - ' ___Liquid depth---- - ------------Capacity -- p Disposal F d: Distance from nearest 'well__ Q----._Distance from foundation__ _/ Distance to nearest lot line-_ ---------- Number of lines____----.-- en th of each line----- Width of trench._ - u l! T - --------------- U10400 th of filter materia -- / �>• Total length----_--?_ ----------------_ Type of filter matenaL�- .iK- p Seepage Pit:' Distance to nearest well----------------_-_-Distance from foundation-------------------.Distance to nearest lot line-_-_------------_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------------_ --- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------- - ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from rearest well_-_----------------------------------------------Distance from nearest building------__-____------_---_------------_.-. ❑ Distance to nearest lot line----------"---------------------------- ---------------------------=--- ---------------------_------------------------------- --------------------------- Remodeling and/or repairing {describe)-------------- ----------------------------------------I--------------------------------------------------------------••- --------------------------- ----------------------------------------------- =---------------•-------------•--------------------------- •------------------------------------------------------------- I hereby certify +hat I have prepared this application.and that'the work will be done in accordance with San Joaquin County ordinances, State la , and rules and regula)jons of the San Joaquin Local Health District. (Sig ----------------------------------------------------------(Owner and/or Contractor) 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 APPLICATIONACCEPTED BY------------------------------- --- 4--- ----------F-- -----------------------•---------------- DATE--------------------------------- ------------------------- REVIEWEDBY-------------`---------------------------- -- - -- --- ------- ------------------------------------ DATE ----- �--�".: -------- ---------- BUILDING PERMIT ISSUED--------------.- � -- - ----------- - DATE__ -- - •----------- �/ Alterations and/or recommendations--------- -- --- �f ". '----------------- �� =la'd elf..--1.�P.[ 'r -------•------------------••----------------... ---------------------------------- .-- - -------------------- ----------------------- FINAL INSPECTION-BY------------------------- ------------------- •---------------- Date------- ------------ -- ----- ------------- `- 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-9-21x1 , Revisea 1-57 F.P.CO-