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APPLICATION FOR SANITATION PERMIT Permit No. ...... � (Complete in Duplicate) d` �' ---1___---,---- This Permit Expires 1 Year From Date Issued Date Issued ------ 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-Ido.-549 . JOB ADDRESS AND LO ATION..,??Y/._._._._. __ ---- ---------------------- Owner's Name. --------•--- - --- -------------� ------------------- ---•-------- -----= . Phone I � ti Address --- ------------= ----------------- -------------- -------------- = - i Contractor's Name------------ Installation = = = Phone------ ------------ 1 Installation will serve: Residence 8<Apartmenf House t❑ Commercial ;❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ____ Number of bedrooms__ Number of baths _: __ 'Lot size __ _ Q ------------------- ,�' ------ , "A -- Wafer Supply: Public system [Community system ❑ Private.0 Depth to Water,Table -30-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--lPardpan ❑ Previous Application Made: Yes E] No V New Construction: Ye's' ❑ No [ FHA/VA: Yes ❑ No R�' TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.),s{ iSeptic Tank: Distance from nearest well____-_-_-___---;Dist n e from foundation--------------' ------------------------------------------------- ELe No. of compartments-------- -----------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from neares+ well-----------------Distance from foundation.......--------------Distance to nearest lot line------------------ Jam' ❑� Number of lines---------4-------------------------Length of each line---_---------------------------Width of trench------------------- ------ Od Type of filter material-----------------__-----Depth of filter material----------------------- otal length-----------------:----------------------- rte' Seepage t: Distance to,nearest well-- ---�•-----.--Distance fr m foundation---/D-'_--_-.-D" t ri � to nearest I t limn-e---�-.-.---_ Number of pits._..._'----.-----Lining mate rial-_1CA94,e---Size: Diameter- 5 ---------Depth---A�{. �-------------- Cesspool: Distance from nearest well-----------------Distance from foundation....-- _------ material-_-----------.-.-------------------------------"_.-_ ❑ Size: Diameter-- �-----.--------------- -----------Depth--------------------------------- ------ -----------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------ ----- -- - --_Distance fromnearest building� 9-------------------------••-------:----- I ❑ Distance to nearest lot Iine------------------------------ --------------------------------------•-----------•--------•----------------------------------- 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 rule and regulations f.the San Joaquin Local Health Disfric+. r Contractor (Signed)-------------------------- - - - ----------- ----------------- I By:---••-------•-•-•------------------•---•- -- ---- -;--4.-------------} (Title)---- �-`� ................. (Plot plan, showing size of lot, location of syst in relation fo wells, buildings; etc., can be place- d on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY... -_- ---- ---- =------ DATE------5� �`� � �--------------------- REVIEWED.BY------------------------------------------------------------------ ------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DA•TE--------------------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------------------------- -------•--------------------------------------- -----------------------°-------------------------------------------=--------- ---------------------------------------------------------•----------------------------------•-------------------•--•--•------ --------------------------------- - ------- ---------•--•--- ----•-----------------------•----------------------I------------------------ ----------------------------------------- ----- •-------•------- -- --- - ------- - ---- FINAL INSPE ---------- ---- ---- -- Date /..-- -`-----r �0 ------------------------------------------------ .14 4 SAN JOAQUIN-LOCAL HEALTH DISTRICT 130 South American Street t 300 West Oak Streot f 1132 Sycamore,Street 814 North "C" Street d �- Stockton, California Lodi, California " Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.Co.- i ,+