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APPLICATION FOR SANITATION PERMIT Permit No - / (Complete in Duplicate) iffiNibbDafe . -.i�a-�- issued ----�/_-1�--��- 1 This Permit Expires 1 Year From Date Application is ereby made to the San Joaquin Local Health District for a pe to construct ' install tljepwos�srai escrb d. This application is made in compliance with County Ordinance No. 549. — ((cc JOB ADDRESS AND LOCATION- --' ��yyyy��.. /� �/ �� Phone------------------------------------ Owner's Name _yA--- -�,} _ Address------------- ----- ------------ ---- -- --- -- Phone Contractor's Name ------- --------- Installation will serve: Residence ❑ artment House;❑ Commercial E] Trailer Court E] Motel Other Number of living units: Number of bedrooms _X Number of baths _ Lot size ___-- _----------------------------------- - ! r Water Supply: Public system El Community system (0 Private. Depth to Water Table . a_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand-y Loam ElClay Loam ElCiay ❑ Adobe&, Hardpan E]Previous Application Made: Yes ❑ No.,� New Construction: Yew o �HA/VA: Yes ❑ No ®— TYPE OF INSTALLATION AND SPECIFICATIONS: y �+ (No septic tank or cesspool permitted if public sewer is available within 240 feet.).,,* Septic Tank: Distance from nearest well-----------------Distance from foundation----------------- Material----.---_-----------------------------------_---. El of compartments--------------------- -----Size------------------------- Liquid depth--�-- Capacity Disposal Field: Distance from nearest well ----_-Distance from foundation-_---_-_-_-------_-Distance to nearest lot line----------------- ❑ Number of lines-----`-----------------------------Length of each line--------------------- --------Width of french------------------------------------ ti of filter material--------------------- DePth offilter material Total �lengf h------------------------------------------- + .__•.---.Distance;to\nearest lot line- -�---_ Seepage Pit: Distance to nearest welly----/ -:------Distance from foun ation__ Linin material_---- d C'-- -Size: Diameter.:--• -------- -Depth-.-_-_ -----_----- Number of pits---_�_- - -- g ¢� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------- -------------------- -s ❑ Size: Diameter--------------------------------------Depth------------------ --- Liquir� Capacity gals ------------- O Privy: Distance from nearest well----.-_------------------------------------------Distance from nearest building-------------------------------------- --- ❑ Distance to nearest lot line--------- ------------------------- --------------:----------------------------------------------------------- - Remodeling and/or repairing (describe)--------------------- --------------•-•----------- ------------------------------------------ ----------•------------•-------------------------------------------------------•---------------------------- -------------------------------------------------•--------------- - - -------- ------ ------------=------- ---- --- --------- - --------------------- ----------------------------------------------- -- 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 and regulations of the San Joaquin Local Health District. (Signed)__ (Owner and/or Contractor) ------- ------------- Y - - --- ---------"+--------(Title)---------- ------ - -----.- --------- ----- -- ---- -- ------ (Plot plan, showing size of tot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----------_------- ---- _ DATE----- --- - -- ---- REVIEWEDBY---------------------------------------------------- ----------------------------------------- DATE -- --- ------�--------------------------------- BUILDING PERMIT ISSUED---------------------------- ---- -----. DATE. Alterations or recommendations:---------- ----------------------------------------------------------------------------------------------------------- -------- --------- ------ ----------- - �i ------ ------ - - FINALINSPECTION BY--------- - --- ----------- - ----------------- Date------- - ---------------- ------------------------------------ ---------------- 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 ES-9-2M Revised 8-'59 F.P.Co.