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APPLICATION FOR SANITATION PERMIT Permit No. .-. (Complete in Duplicate) Date Issued --5 ,..— Applica{ion 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. 549. 1 JOB ADDRESS,AND LOCATION_,_ -- _ ----- --- _d wner's Name--------------- _ " - one Address----------_-----= - ------------ . ---------- - ----------•---- ----•--------------------------------- -----•--- - ------- ---- - -- Contractor's Name........... . . . .. s •----- --- ------ Phone. Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court E] Motel E] Other E] Number of living units: --�__-- Numbe _r of bedrooms / _-_--- Number of baths -_._.___ Lot size __-_____. -------------- Water Su � 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 I Previous Application Made: Yes ❑1 No [g r New Construction. Yes �No TYPP OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well - Distance from foundation-------------------Material_----_-_--__.-._-___-__No. of com artments--------- Size Liquid depth ------•----------p ----Capacity--------------------Disposal Field: Distance from nearest wefi_- Distance from foundation __ _ - .__Distance to nearest lot line.-�Number of lines-I-------------/----------------Length-of each line------1Q----------------Width of trench.-----Type of filter materia(--------- ----------Depth of filter material------------- = Total length---------------------------------------Seepage Pit: Distance to nearest well----------------------Distance from foundation_______________ ---.Distance to nearest lot line---------- ------ ❑ . Number of pits--t------------------Lining materia!-----------------------Size: Diameter-----------------------Depth----------- _---- Cesspool: Distance from nearest well------------------Distance from foundation.-._---.-._._ ---- .Lining material----- �------- Si --------- ---------- i - ❑ Size. Diameter-----_ -------------- ------.-----Depth ----------Liquid Capacity- --------------••---.-----.gals. Privy: Distance from nearest weil______________________________ Distance from nearest building.-, a ---------- g-------------------------• --------------- ❑ Distance to nearest lot line Remodeling and/or repairing (describe):------.._-_ -- . - - _ __ r Coil f ---------------------• ------- •-------•---•------------•------ ----------------------------------------------------•-----•----------------------------------------- --------------- -----------------•---------------- 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 rules andregulations of the San Joaquin Local Health District. --------------- (Signed) BY: r (Title)-- - Contract (Plot plan, showing size of lot, location o stem in relafion to wells, buildings, etc., can be placed on revers sib de). FOR DEPARTMENT USE ONLY ---------------------- -APPLICATION ACCEPTED BY ----------------- EVIEWED BY -------------------------- --- -----------------------------------•-------------- ----------------------- DATE---Y-----------------------•---------------------------- BLJILDING PERMIT ISSUED .---_-.-- DATE.-..- Z ------------------------------------------------ ----------------------Alterations and/or recommendations--------------------_ . ---------`-------- ---------- --------------- ------- ------•------ .l_ --------------•---•------•--•-•----- --•---------- -------------------- ---- ----- F1NAL INSPECTION BY.----. C.' -------------•----------- Date '' `a ��h 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 rS-9-21A 145416 g7W00❑ 12-54 �A