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APPLICATION FOR SANITATION PERMIT Permit No. _- (Complete in Duplicate) Date Issued ____ f Applica-%n 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 AND L C - --- — - .-_ -- OwnersName.-----•----- � --- ------ •-- ----•------- - --- -- -----r--------------- Phone------------------------------ Address...........-........... - �'�- .. ------ - --------- Contractor's Name - - -- --------- - -- 'fit r ---- Phone4K------------------- Contractor's b- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: __�___ Nu ber of bedrooms -.. Number of baths_-- Lot size ~ ---�__-� - --------------------- Water Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Materiaf------------------------------------------------- 4os No. of compartments------------ -------------Size---------------•---------------Liquid depth----------------- ------._Capacity---------------------- DisI Field: Distance from nearest well.................Distance from foundation______-_------_---Distance to nearest lot line----------------- W 4F,t. Number of lines-----------------------------------Length of each line------------------------•- .Width of trench-------- ------JrType of filter material-_____________________ _ epth of filter material____--__.-.-._---_._Total length-__._______•_-__--__-______________--- tj Seepage Distance to nearest well W/ZX____ __ Distance from foyndation__,�O---------Distance to nearest lot iine/d---_.___. IJ.— Number of pits-Ljy.��'-. Lining material.f✓_-Z;r_____Size: Diamete r__�,d,?--------Depth-___ ., `_--___._______ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material---_---------------------------------_ ❑ Size: Diameter----------------- - -----------------Depth----------------------------------------------------Liquid Capacity---------------- -----------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------------------- -- ❑ Distance to nearest lot line-------------------- ----- - ----- ----------------------------------------------------------- --------------------------- Remodeling and/or repairing Idescribe�--------------- ---•-- '--- --- •- -------- ----------- •... --------------------------- ----------------------•--------•---- ------••----------------- ----- ------ 4` ----------------- ------------------•----------------------------------------- -------------•----------------------------•---•-----------------------------------•---------- --------------...------ ----------------------- - ----------------------------•------------------•----------------------- I hereby certify that I have prepared this application and that a work will bp'` one in accordance with San Joaquin County ordinances, State laws, and rules and re tions of the San Joaquin cal Health Distri Or(Signed)--------- �-r " a - -- -- ---- - ----- (Ow and/or ontractor) B . �---- Y' {Title) -- - ----- ------------- :>e (Plot plan, showing size of lot, 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---------------- � N ------ ------------------ Alterations and/or recommendations:-------.-------------- " -----•------ f ------- --------------- - '- ----�- ------�------ --4; ------------------------- ----- ---------- - ----------------------------- --------------- --- ------------------------------------------ ----------------------------------s-----------•---------------- FINAL INSPECTION BY:____ Date - 0 ----------------------------------- - --------------------------------- 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 145446 AT-... 12-54 i