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, r APPLICATION FOR SANITATION PERMIT Permit No. :__ - �_ ___ I (Complete in Duplicate) �n Date Issued ___.,Z,�� 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 with County Ordinance No. 549. JOB ADDRESS A ON LY ------ --- --'-�-�----- -------------------------- Owner's Name----- -- -- _ f- ---------.-. Phoned__ Address--------- ----------- -- ---- - -- -------------------------------------------------------------- ------- Contractor's ------------------------------------------------------- -------------- - Contractor's Name------------------ - -- ------- ------- ------ --- ------ ---=-------------------------------------------------- Phonn 71 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ . rrMotel ❑ Other ❑ Number of living units: .Number of bedrooms j.2_._ Number of baths /_ Lot size ___/__S_- ----_--__---------- Water Supply: Public system 24_�Community system ❑ Private ❑ Depth to Water Table �� ft. "•)' r. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B-74-ardpan ❑ Previous Application Made: Yes ❑ No [ rNew Construction: Yes ❑ No [ FHA/VA: Yes ❑ No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted i ublic sewer is available within 200 feet.) Septic T k: Distance from nearest well _Distanc from.foundation_-- -�__.-_____.Material__ ----------------- / _._-__ tom---------------- No. of compartments__._` --------------Size---� _ s„ _ _----Liquid depth_____ _ -----Capacity______ __ Di �,,, sposal Field: Distance from nearest ellDistance from foundat' n__�Q---- Distance to nearest lot lined-_--_______ Number of lines--------- ___�GLength of each line___(�__Q_`_, --CL'Width of french...... �'___________ Type of filter material_�� ____ _________ epth of filter material____ ____ _ _`/ Total length__ (_�-_-__-------__-___-____-`_ Seepage t: Distance to nearest well -___Distanc m f undation__,3_Q______.Distance to nearest lot line____________ Number of its.-_.___/____._______Linin material__ _ �_ 3-3.11.___Depth ! p g __Size: Diameter___ __ p Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material----------------.-------_____________. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------._______________________._______.._. ❑ Distance to nearest lot line-- ------------------------- -------------- ------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)=----------------------------------------------------------------------------------------------------------------------------------------------- --------- -------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------...------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------ --------------------------------------------------------------------------------------------------------- ------------------------- ----------------------------------------------------------------- I I hereby c r ' y that I ha v aired this application and that the work will be done in accordance with San Joaquin County ordinances, St I ws, d r es a regulations of the ASanaquin Local Health District. Z(Signed) caner and/or Contractor) _ By:------------------------------------------- (Title) (Plot plan, showing size of lot, location of system in relation to well ildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- -- - - -- - ------ ---------------------••----------------------- DATE---- REVIEWED BY--:--- - - --------------------------- DATE-- BUILDING ATE-BUILDING PERMIT ISSUED--- ---------- -�-- ------------------- - ------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations-------- ---------- ----------- - - ---- -- --------------------------------- ----------------------------------------------------------------------- ---------------------------•--------------------------•- -•----------------------------------------------------------------------------------------------------•------------------------------------------------------------ -------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION - BY:-- �Uv� --------•------------------- Date....' �, -------P--------J-1`�- ------------------- V----- ----------� SAN JOAQUIN LOCAL HEALTH DISTRIC 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.CCF.