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APPLICATION FOR SANITATION PERMIT Permit No. �n a (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 complianceAiiiounty Ordinance No. 549. , , , JOB ADDRESS AND LOCATIO ---------- --- ----------------------------------------------------------•------------� Owner's Name . f } ------ Phone--,-------------- -----•-------- �' _ = Address_. _: y " -� •--- ------'--------- -- :- - ---------------- Contractor's Name - ---------------------------------•---------------------- Phone----------------------------------- Installation will serve: ResidenceApartment House ❑ Co ercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ -. i Number of living units: _ Number of bedrooms _Number' of baths1____ Lot size ________________________ Water Supply: Public system ❑ Community system ❑ Private epth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam Qlay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ FHA/VA: Yes ❑ No 0� TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or'cesspool permitted if public ssewer is available within 200 fe f.} , Septic T Distance from nearest welLc��-----Distant from foundations --.Mater al No, of compartments____`�e..-�_ _-__Size-_ __ �z�l (__Liquid depth___xistarice ____________Capacity.__..--PA 1(_ -___ . Disposal Distance from neare t weil_�-�-----Distance from foundation_ _ to nearest#jlf ine_-. _____.___/ Number of lines_____ _ f I___- 4_.__ ength of each line-- 1�i - .Width of trench.____ -�Type of filter material _ -- epth of filter material_f ll_______Tota[ length_-f ----------------------------- Se ___________________ Seepage Pit: Distance to nearest weft----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------- ----Depth---------------------------__---- O Cesspool: Distance from nearest well-----------------Distance from foundation---.----------.____.Lining material_____._____________________-______ ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. p` Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__________----------_-_________________._. !" ❑ Distance to nearest lot line-------------------------------- -------------- -------------------------------------- Remodeling ----------------------------------Remodelin and/or repairing describe µ r.,--."---- ` f; ♦Y i d 1, _____________________________________._______________ { � l I I hereby certify that I have prepared this application and that the work will be done in ac o dance with San Joaquin County ordinances, Stafe laws, and rules and regulati ns of the San Joaquin Local Health District. -• � i ASigned}----1c-1-fir ------- By: _- - __ ----•-------------------(Owner and/or Contractor) f3 - (Title)_ (Plot plan, showing size of lot, location of,system in.relafion to wells, buildings, etc., can be placed on reverse side). - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- ----- ----------------------------------------------- DATE------------------------------- { REVIEWEDBY------------------------------------------------------------------- ------ ----------------------------------------------- DATE----- _�------------------------- BUILDINVYERMIT'ISSUED='---------=--------=-••-------- --------------------------------------------- DATE----- -- ---------------------------------- Alterations and/or recommendations------------------- ----------- ----------------------------------------- �� - ---------------------------------------------------------------- •------ ------------------------------------------- - ----------------------- ------------------ ------------------------------------------------ -- ---- -- --------------- --------------------------------------- -----------------------------•---------------------------------------- F FINAL WSPECT ._ Date------- r f------ - - -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California s Lodi, California Manteca, California Tracy, California ES-4-2M Revisaci 1-57 F.RCO. I