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APPLICATION FOR SANITATION PERMIT Permit No. cfl (Complete in Duplicate) 1� Date Issued/ Application is hereby made to the San Joaquin Local Health District for a pe mit fo construe and install the work herein described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCATION___.._ wner's Name---------------"_-- - Phone� 10_:0--------- Address ------------------------•-•--•----- f_ `rI ---- --------------- /' Of------------ Contractor's Name - -""' ""' -- '- ---••----•- � --�----------------------------- Phone--------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 4� ❑ otes❑ Other ❑ Number of living units: __1---- M """" Number of bedrooms ___:0__ Number of baths Z--- Lot size _ - ` - - -- Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [) Adobe Hardpan ❑` Previous Application Made: Yes (] No�-` New Construction: Yes 0_ No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public se er is available within 200 feet .� Septic Tank: Distance from nearest wellDisfau. %,fro fou &a_� No. of compartments------'� -------- - 1Z J �Gj ----- .Materia!_ ,�`r ,Y /� ------------------ - -.---•---Liquid depth-- - ----------Ca aci Dispos i Field: Distance from nearest well r` p ��- "'- __",Distance from foundation___,` Disfiance to nearest lot lin _ Number of lines__ s'' �� -- -- ---Length of each line_-------`�' Width of trench__;�--�--------------" Type of filter material__" "" __-____. __-_Depth of filter material__/r , / � ----------Total length c�------------- Seepage Pit: Distance to nearest weil__________________---Distance from foundation----------------- Distance to earest lot line_"_______________ ❑ Number of pits-------------------- Lining material-----------------------Size: Diameter---------------- Cesspool: Distance from nearest well-----------------Distance from foundation______"-------------Lining materrialth-__-------______"_________------_ ------------- ---------------------------- ------ N ❑ Size: Diameter------------------------------------- Depth---------------------------------- -- - _ Liquid Capacity------------- -------------gals. Priv - - ,. __ � Y: Distance from nearest wellDistance to nearest lot line----- - ------------------------------------ Distance from nearest building ............... __ ____--------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):__" I hereby certify that I h ve pre ared this a ication and that the work will be done in accordance with San Joaquin County ordinances, S to I , a d ules regulatio of the Sa Joaquin Local Health District. (Signed)-- xf' ----- ----------------------------- ------ B r ntract o C or) -- --------------- --- - ----------------(Titl*pe4'on ---------------- (Plat plan, o size of lot, location of syste in relation to wells, buildings, etc., can be reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ DATE___-_ REVIEWED BY------ - � �------------ -�------�--------•---------------- --------------------------------I---------------- BUILDING PERMIT ISSUED----------"-"--- ----D--A---T--E------------------e--- ATE-__ - - -------------------------- ---------------- DATE: Alterations and/or recommendations:_ ""_---" ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------•------------•--- --------------------------------------- _ �Z---------- f-------j4-<<-------- ,., ------------ - ------------- ----------------- ---------------- ------- --------------------------------------------------------------------- ---- 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-9-2M 8-51 Revised W-2100