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APPLICATION FOR SANITATION PERMIT Permit No. .... om lete in Duplicate) �CP Date Issued This Permit Expires 1 Year From 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 i C my Ordinance No. 549. JOB ADDRESS ANALATION__ F = Owner's Name+ - - ' Phone._' 4 , Address -. - - ------• ----- •---- .__. .-----•-_--- Contractor's Name_`r -- ----- ------.__ Phone. ---�i,�e Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ Number of bedrooms -%--- Number of baths _______ Lot size ------------------ Water _Water Supply: Public system ❑ Community system ❑ Private j Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand- Gravel ❑ Sandy Loam K Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No-O--New Construction. Yes ❑ Nort6,FHA/VA. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well.V_f____Distance from foundation__/�;7`_.__--Material-__GC'±______________________________________ No. of compartments____f ------------------Size Uq _ _ . ________Capacity y----eF9�-----Li ------ Liquid de th Disposal Field: Distance from nearest well. r..._Distance from foundation__- _____-Distance to nearest lot line----Z.!______- Number of lines________------------------Length of each line---. /-________._._.Width of french---a?- !r______________I Type of filter material_ __ -__Depth of filter material-____/_ ----__Total length_________f_4f.?__!__________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------------•---------------gPrivy: Distance from nearest well__-_.__..______________________________________Distance from nearest building.__._...______________________..____❑ Distance to nearest lot line ---------------------------------------------------------------•------------------------------------------------------------------------ Remodelingand/or repairing {describe):------------------ -- --- ----------------•--------------------------------•-------------------- -------------------------------------------------------- ------------------------------------- --------------------------------------------•-------------------------•--------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --- I hereby certify that I have prepared this application nd that the work will be done in accordance with San Joaquin County ordinances, 5 I s, and rules nd regulat' ns of the an Joaquin Local Health District. [Signed) ( r1`f -------------------------- r Contractor) B (Title] Y• ------- -- - ----- ------------- ------------ ----------- ----- (Plot plan, showing size of lot, location of system in relatio �w.ells, buildin , etc., can be placed on reverse side]. ART ENT USE ONLY APPLICATION ACCEPTED BY_______ .. __ .___ DATE------ - -------------- REVIEWEDBY--------------------------------------------- ----------------------------------- -------------------------------------------- DATE---------------- ------------------------------ - BUILDINGPERMIT ISSUED----------------------------------------------------------- ------------------------------------------- DATE--------------------------------- ---------------------_-- Alterationsand/or recommendations-------------------------- ---------------------------------------------------------------------------•--------•------------•-------------------------------- -----------------------------------•------------------------------------------------------------------------------------------------------ --•----•--------------•----------------------------------------------------------- --------------------------------------•---------------------------- ------ - ----------------------------------------------------------------------------- ----------•-- --------------------------------- FINAL INSPECTION BY:..... Date-- - . �+°..0 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 FP.Cc.