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APPLICATION FOR SANITATION PERMIT Permit No. ------- (Complete in Duplicate) C/—Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and1ir7 C/the�7 Z-0(described. This,application is made in compliance with County Ordinan No. 549. YY sa' JOB ADDRESS AND LOCRTION__ �, �a�CJ ` -- Owner's Name-----L_�_ ' Y } Phone Address------- -• ^ ------- --- -------- - ----- ------ ----- *------------------- ----------------------•----------------------- Contractor`s Name ------ Phone--- - ------- -- ------------ - Installation will serve: Residence .❑ Apartment House ❑ Commercial ❑$Trailer Court ❑ M tel Other ❑ Number of living units: _11 Number of bedrooms _ l_ Number of baths It Lot size .___ _ � --------- Water Supply: Public system El Community Community systern' Pfivate 'Depth to Water TablellKXYT, Character of soil to a depth of 3 feet: Send"❑ Gravel ❑ Sandy Loam L) Clay Loam ❑ Clay ❑ Adobe42- Rardpan [] Previous Application Made: Yes ❑ No New Construction: Yes ❑ No Z?' FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer•i vas ailable within 200 feet.) Septi Tank: Distance from nearest well_________________Distance from foundation---------------------Material Nof compartmentsfli _ _-------Size------------------------------ Liquid dep th = Capacity ---------------- bispo Field: Distance from nearest well_________________Distance from foundation_---________________Distance to nearest lot line-----:__-__----_ �1 Number of lines----------------------------------Length of each line-------------------------------Width of trench ff f Depthl A ,-c--. r ------------ O f talc .___..Di f to nearest lot _ Type �y --- Seepag Pit: Distance toeneara sf'well_ ---1�-____ D stance(fromrfouteatilon__ Tota( length---------------------------line__ si -_---_ 1 Number of pits-----/-------------Lining material Size: Diameter___I --- Depth------ozz'__/ --------- 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 line1 Remodeling and/or repairing (doscribe)--------------- l C Y r { --- - -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- -----_--------------------------------•--------------•-------------=------------•-----•----------•----------^'------------------------------------------------------------------------••----------------^------___-_____._ - ------------------------------------.. --.------_-- ------------------------------------------- .-•---------------••--------'---------------------•-------------------------------------------------_-----•------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t ordinances, State laws, and ules and . regul tions of +h San Joaquin Local ealth r!District. -- - ------ --� E. �(Signed] �------------( Contractor) By:-------------;--------- --•-- ------ (Ti+le] ! — (Plot plan, showing size of , location of system in relation to wells, buildings, etc., can be placed on rever side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- -------------------- -- ---------------------------------------- DATE n REVIEWEDBY----------------------------------------- ----------------------------------------- DATE------- - J V BUILDING PERMIT ISSUED----------------------------___ - ------------------------------------ -- ------------------ DATE------------ Alterations and/or recommendations_______ __ _ ________--_-__-------_-__. -_ _----_---_-_ t --- -------------•----------.-...----------- •---...._.... ------ —p-. ------------- _, a---------- ------------- ---------- `e-------------- --------------------•-- -------------------------- ----------------------- ---------------------- ----- !¢ . ---------------------------------•-------------- ------------- ----------^--------------------------------------------------------------- 4 FINAL INSPECTION BY:__- _ .._ - Date------ ----------------------- / -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street '300 West Oak Streaf'x 132 Sycamore Street 814 North "C" Street Stockton, California . Lodi, California Manteca, California Tracy, California ES-4-21x1 Revised 1-57 F.P.CO.