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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate Date Issued --- - �--'--- r12�.3�nf.-.. 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 AND O ATION----- ` % --------------- --- - Ow ' Name - -------- --------- Address -r. Phone Aes_ ------` - �. )�I = h - / -�� -- ----- Contractor's Name------------ ----•` - _ -- ------ Phone------ --- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other d❑-' Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ----- - , . ------------------__ Water Supply: Public system ❑ Commursity system ❑ Private f Depth to Water Tables ft. Character of soil to a depth of 3 feet: Sand ❑', Gravel ❑ Sandy Loasm ❑ Clay LoamClay ❑ Adobe ❑ Hardpan ❑ „ Previous Application Made: Yes P-_�No ❑ Nei Construction: Yes [A No [�FHA/VA: Yes E] No E]TYPE OF INSTALLATION AND SPECIFICATIONS"-{I l (No septic tank or'cesspool per`mifted -if public sewer is available within 200 feet.) $ •c an Distance from nearest well----------------Distance from foundation-_.----_--_____-.Material_------_____-----_..-__-._--__---_-_.---___-_--. No. of compartments--- ---------t------------Size--------- --------'----------Liquid depth,-------------------------Capacity----------------------- Disposal Feld: Distance from near est well/W--------Distance from foundation_-d_f__-.-.Distance to nearest lot Number of lines,___-__l`1------_____ Length of each line____tL�--__-_�®_-.-.Width of trench-__ /r 1 -------------- Type of filter material.. f -Depth of filter material------ ---------Total length____�it] ________________----_----_ See ,,Kit: Distance to nearest well_,/ry _ _--Distance r m` f�roundation____ -�_._-.Distance to nearest lot line_-i Number of pits..--_�--------------Lining material _ .Size: Diameter-----_ Depfn______c�_�__---__.-------_-_ 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.-.-_-.------------__--`- Remodeling and/or repairing (describe):--------- ------- ------------------------------ ----------------------------------------•---------------------------------------------------------- ------ ----------------------------- •----------•------------------------•------------------------------------- --------------•----------------------------------•---------------------------------------------------------------- ------------------------------------------------------------------------------------------ ------ I hereb -certify that I ve prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St t law an r es and reg I tions of the an'Joaquin Local Health District. (Signed)---:- � --------- ------------------------------------ --- Owner and/or Contractor) �Y• �� - - ' -- `-- (Title) ------- . (Plot plan, showing,size of lot, Iocation of system i r ion to Wells, buildings, etc:, can be placed on reverse side). ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED - --------------------------------------------- DATE_ • ---------- ------ ---------------- -------------------------------------- REVIEWED BY -- --- DATE- BUILDING PERMIT ISSUED_..... - - ----------------------------------------------------------------------------------• DATE- Alterations ATE Alterations and/or recommends ions-- --- ------------------------------------------------------------------------------------------•--- ----------------------------------------------------------------------------------------------------------------I--------------------------------------------------------------------•-------------------•------------------- •-------- FINAL INSPECTION 13Y:.--, --------------------------- Date---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9---2M , Revised 1-57 F.P.CO. 1