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2pa�t �a APPLICATION FOR SANITATION PERMIT Permit No. .��:.?. (Complete in Duplicate) Date Issued � 7`-• Application is hereby made to the San Joaquin Local Health District for a permit to constructan the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND CATION s__ ' .P�- . .... Owner's Na .�4 - --- � � _ Phon fc Address-----------------s _ ,!_-- - -- - Contractor's Name -- -•------ ---------- Phone ,. . Installation will serve: Residence- Apartment House ❑ Commercial ❑ Trailer- Court ❑ Motel ❑ Other ❑ Number of;living units: ___ ____ Number of bedrooms ____ Number of baths __/___ Lot size.__ Water Supply: Public system Q Community systemivate ❑ Depth to Water Table ........ t. Character of soil to a depth of 3 feet: S;��NewConstruction: vel ❑ Sandy Loam ❑ ay Loam Clay ❑ Adobe❑ Hardpan F1 Previous Application Made: Yes ❑ No Yes le No ❑ FHA/VA: Yes Q 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/ ____Distan om u� tion____ �___._. a r No. of compartments_,__ __--_-p__,-____Size_ --------__.Liquid depth-? _________Capacity.t� Disposal Fiel Distance from ne st well t _Di n te from foundation . Distance to nearest 1%t line .,'.�r Number of lines- ..__.,_ <__._.__Length of each line !_____ d.r___,Width of trench_ �.'.+___ _.__.,:._ Type of filter materiau Depth of filter material /,P� Total length._.:. 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-------- --- ------------------Depthk:- ----- •----- - --_---..........Liquid'Capacity........................_gals., Privy: Distance from nearest well----------.----------------_------_---------- ___Distance from nearest building____=_ _.--------------------------------- Distance --,_-__ _--_•____._.__.-•.Distance to nearest lot line------------------------------ ----- - •------- ---- ......- ............. ............ Remodeling and/or repairing (describe):----- -- -- ---~-•---•---- ................................................... .•-••-- ••--...........................=- •••••--•- I hereby ertify that I have prepared this application and that the work will be done,in accordance with San Joaquin County `4 ordinances, to laws, an rules 4nd regulations:o!LSan Joaquin Local Health District. Si ned �j rte, ( 9 ) -- -----•. - ----------_------- - , +ep modCG�c-Con}rectorj. By:..........._....................................................... --------•-- ----- Title------------------....................... ----- -- (Plot plan, showing size of let, location of system in relation we 'Idin-gs, c., can be placed on reverse side).' ; FOR DE ARTMENT USE ONLY APPLICATION ACCEPTED BY.. DATE.. ...._....�+�: REVIEWEDBY............................................------ -------- ------------------- - ............................. DATE.......... ••••-•:: ....._-_.. .._._. ._._.... BUILDINGPERMIT ISSUED_-- •----••-.---••--- -•------ - ••-•• -•-••----------------------------------------- DATE ------•- •-•----•----•••-•• •----•-•----_---••- Alterations and/or recommendations:_ ----- - ------= -------- ---•••• -•-•----• .............................................................................. ------------ ------- --------------------- ---- FINAL INSPECTION BY:. --------- Date - ?" -•---f- ............. ----• -------------------- SAN •- --- - -- SAN JQAQUIN 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 Revised 1.57 F.P.CO.