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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) •� .. 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 ithoQ Ordinance No. 549. JOB ADDRESS AND LOCATION_ __-.1 �- `' _ Owner's.Name � _ --- ---- Phone---:- -r--- --'----------- - Address ` -'-`-------- -------------------------------------------------------•-- -- --------- Contractor's Name----------------------- "r -------- -------------------------------------------------------------- Phone Installation will serve: Residence Q� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __)___ Number of bedrooms ,.__---- Number of baths f/I/Lot size _____/�,�__ _ _ ___ _________________ Water Supply: Public system E] Commun'ity system ElPrivate [o/Depth to Water Table -------- ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel D. Sandy Loam p' y Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No © " ew Construction: Yes D�o ❑ FHA/VA: Yes ❑ No ❑�. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.), Septic Tek' Distance from nearest wellt �- --------Distance from foundation---/C1............Material____ - -t ` `" ---------------- of compartments--7 -----_----f-----Size---q-.X-�_x_�-----Liquid depth------ --------------- No. Capacity----- _ Disposal Feld: Distance from nearest well___577 -------Distance from foundation____A!----_-__._.Distance to nearest lot l)'ne---4 -�____ � [ / Number of lines---.-------�------ -----------Length of each line------ --------------------Width of trench_.__ --- ------------------- Type of filter material____-YIT A �/ ---- -------Depth of filter material-----Lk-------------Total length--------JI-1f�_'-_--_--____________------ Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line----------------- � r ❑ Number of pits--------------------- •`Lining material-----------------------Size: Diameter-----------------------Depth-_---------.--------------------- -v Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material----------.-_____----_-------________. ❑ Size: Diameter----------------------- ------------Depth--------------------------------------------------._Liquid Capacity----------------------------gals. 0 Privy: Distance from nearest well------------------------------------------------Distance from nearest building_____._.-____________-___-------_--.---__. ❑ Distance to nearest lot line---------------------- --------------- b Remodeling and/or repairing (describe):-----------------------------------------------•-------------------------------------------------------------------------------------------------------- ----------- -- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------- I hereby certify.that I have prepared this appl' ation and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulation s a he San Joaquin Local Health District. -----;� --�------ ----�-- � - - -----(Owner and/or Contractor) ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- _. �{.tM %w�'". = __ DATE. '3........ T / �-`1 --------- ---------------------------- REVIEWEDBY--------------------------------------------- -------------------•----------------------------------------------------------- DATE----- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterationsand/or recommendations:----------------------------------------------------------------------------------------------------------------------------•-------------------------------- -1-------------------------------------------------------------------- -------------------•-------------------------------------------------------------------- ----• --------------------------------------------------------------- ----•--•----------------------------------- -----------•--------------•-_-- FINAL INSPECTION BY-------------------_1_--- •---------------- Date------- Z� r --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street aro North "C" Streef I Stockton, California Lodi, California Manteca, California Tracy, California k ES-4-2M , Revised 1-57 EP.CO. I