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3 APPLICATION FOR SANITATION PERMIT Permit No. l -• -.---______ (Complete in Duplicate) � f", � � �1' � 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 compliarice with County Ordinance No. 549. 'JO�ADDRESS ANDOCATION- ------y _(- y -------------------------- //--� --------------•--------------- ---------------------- Owner's Name------- - ��*�� !/�Z. �I / - - -------------------------------------------- ------. Phone -----------•--------------------- Address--------------- .-_ d- 'f'/-------------- ------------------------------------ Contrac#or's Name ------------------ Phone - -------------- --- -- ---- -------------------- --------------------------------- Installation will serve:. Residence (� Apartment House ❑ Commercial Trailer Court❑-- � ❑ Mote` ❑ Other ❑ Number of living units: -/---- Number of bedrooms -_ Number of baths ____l_ Lot size ----.4�f-X-/�___ Water Suf.pply: Public system �f Community system ❑ Private ❑ Depth to Water Table g.! „_ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel.0 V Sandy Loam ❑ Clay Loam ❑--•Glay❑ Adobe [D/ Hardpan ❑ Previous Application Made: Yes No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No IU/ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.( eptic Tanl r Distance from nearest well-----------------Distance from foundation-------------------Material---------____-_-__---.-_____ No. of compartmenfs--------------------------Size---------------•-------••-------Liquid depth-------- -- -- Ca aci / - - i - P tY-•--------------------- Dispo�al Fiel Distance from nearest weff__-__o`J _.._,Distance from foundation_-_-/a___-___.Pistance to nearest lot line---4.�----- w. . © 711rNumber of lines---------------f,�� Length of each line---.-- _Width of trench-__--_- s---------------- < e ----. 1Total length-__------Typf __ epoermateria__---- >----------- Distance -_ --_ Distance to nearest well � _ `' Distance from��undation----ZQ.-....-..Di ta� to nearest lot line__��V______ I�lgmber of pits- ;__.�----------Lining material--s _"_�'h ize: Diameter_-. _ Depth 4f�----------- ----------- . Cesspool: Distance from nearest well----------------Distance from foundation_--- -------__..Lining material-__-.----------____-.---------------- ❑ Size: Diameter ----------Depth------------------------------- Liquid Capacity gals. ! --- Privy: Distance from nearest weft---------------------_--------_------_--.-----Distance from .nearest building _______________ ❑ r' Distance to nearest lot lire ------------ ------------ d Remong and/or rvairing (de gibe):------ ' x t� z t L� �� ec� --- ----------------------------l - ----- ------------------------------ --- ----------------------------------------------- ---- -I hereby certifythat I have prepared this application and that the work will"be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. F 4 - By:.- ----- -- ------------------------------------: -----------------------------------(Owner and/or Contractor) - ------------ - - - - - - ------ -----(Title)- --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, a#c., can be placed on reverse side). • aJ Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- --------- ----- --------- - ------------------------------------------- DATE--------J� rr REVIEWED BY ----- DATE-----�iex --- - - ------------------------------------------ ---------- ------------ I'ERMIT ISSUED--------------------------- - - ------------------ ------------------------------------------------ DATE--------- - Aterations and/or recommendationsz_______________________ __ � ----------------- -- ------------------------------------------------------ -------------------------------------------------------- - i ---- °- ---- -------- ---1-1----------------- -----------------•-- .------- ----- -- --- -----------•---•------•------ ------ ------ 1`-- -: � - -mac--� -----•-----f----- ------ ---- --- �'-------------- ----- --------------------------------------------------------------------------------------------------------------- i FINAL INSPECTION BY:.---- ---------------------------------------- Date------- 6 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh 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•57.1=.P.CO.