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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued .__L=fi/- App0 -1 lication is hereby made to the San Joaquin Local Health District for a permit to construct and insta I th r ,0'rl elfin descriE. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND �OCATION _ ,-- - �- ----- ----- -- - --- ---- ------ ------------------ - - ------------ Owner's Name-____ - == - - ----------------------- ------ -------------------•--- Phone--------------------------- ------ Address-.___ Contractor's Name_________________ _ - - - ---------- -=---�----- --------------------------------------------- --77� // - ----- --• ----------- ---------•-----------•---•-- - - PhoneN'd fir_----��6�---- - ------------- - nstallation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: ____/(Number of bedrooms _„l_._ Number of baths __!-_ Lot size _• _ -or -- Wafer Supply: Public system ❑ Community system ❑ Private Depth to Water Table A.?_- ft. Character of soil to a depth of 3 feet: Sand Gravel 101 ❑ San Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes.❑ No New Construction: Yes [j No DZ' FHA/VA: Yes j] No ❑ TYPE OF INSTALLATION AND,SPECIFCATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic TJank: Distance from nearest well__ --r__Distance from foundation--a-0-1) -------- Mateal No. of compartments--------- --------e- ' • - - ---------Liquid dap#h---- ----�------- capacity Disposal Field: Distance from nearest well_ 11�.p__.-_Distance from foundation__�yQ__(____.__Distance to nearest lot line_. - -••, `[ Number of limes----------- ----" _----- Length of each line---#Q-f-_ t------__---- Width- of trench- Type fi ____" of filterr.material___�i---- -- - , -- pDe th of filter matenal_____ f� ------ ---- �_- --•- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------To#al length ---------------_•__.Distance to nearest lot line______-____.__.__ ❑ Number of pits----------------------Lining material----------------------.Size. Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well________________ Distance from foundation-------.------------Lining material------------------------ 0 Size: Diameter-------------------------------- Depth------------------------------------------------- •-Liquid Capacity-------------------- ------gals. Distance to nearest lot fine_ Privy: Distance from nearest well------___.___"_________________________-_.____Distance from nearest building -------------------------- n ______________ Remodeling and/or repairing (describe)______________ - -- -----------------------------•-------- ------------------ ----------- ----------------------------------- ------- ----•---•------•--•---------- I hereby ify that Ie prepared this application and that the work will be done in accordance with San Joaquin Cou ordinances, St fe aws, d Ie and regulat s of the San Joaquin Local Health District. (Signed)....------ ^. --- -- -- ---- --- By:--------------------------------------------------------- and/or Contract -- ner o ar) -------- - - -------------- Pot plan, showing size of lot, location of system in relafion to wells, ildings, efc., can be placed on reverse side). FOR DEPARTMEN USE ONLY APPLICATION ACCEPTED BY------------- "-_ - DATE_•_____-_ REVIEWED BY------------------------------------ ` r - 1 DATE ,5---- BUILDING PERMIT ISSUED----------------- --- -- - C ------•------"•----------••- ----------------------------------------- DATE ---------------------------------------------------- Alterations and/or recommendations:_.-_______ _ ------------------------I-------- FINAL INSPECTION 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 1.57 F.P.CO.