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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in 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 with CountyOrdinance No. 549. JOB ADDRESS AND LOCATIO 2 ---- Owner's Name- - ---- -------- ---= ' �--- ----------- Phone------- -------------------------- ---------- --------------- Address a " 1 ----. _ �` ----------•-------------------•-------•--------------------------•----------------- -- ---- Contractor's Name-- --------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: _ ;,-Number of bedrooms ._ _ Number of baths - r Lot size -_ _!(o-a -. Water Supply: Public system Community system Y Y ❑ Private ❑ Depth to Water Table ___.--_. ft. Character of soil to a depth of 3 feet: Sand 1 Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes ❑ No Yr Construction: Yes No 0 FHA/VA: YesNo TYPE OF INSTALLATION AND SPECIFICATIONS: ❑ ❑ (No septic tank or'cesspool permitted itpubiic se w,7 is available within 200 feet Septic ank: Distance from nearest well_ "'__ Dista c fro ou tion-_f -_. ----_.Material 210 No. of compartments -- g if ----- p ---------- Size Liquid depth- '. ..--_Capacity._! - Disposal Field: Distance from nearest welt_ _- r - --� +stance from found t' ® Number of lines___- ---_ _ 3' '�` -Distance to nearest lot�l.ine_t.F�? - -------------Length of each line- -41- Q____E�_ __ Type of filter materi Fof Width of trench_---._---- _ -- . - " DEpth of filter material----•-,- ---__ .-Total length.-------- - ------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation___ --.----•-__-_-_,Distance to nearest lot line-------- ------ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter------------- --------Depth---------------------- - Cesspool: Distance from nearest well-----------_-.--Distance from foundation--------------------Lining material-_.---__--_------------------------- ❑ Size: Diameter.---------------------------------- Depth---------------- \ ' ----- -------- ------- --- ------Liquid Capacity-- --------• -------• ----.gals. \, Privy: Distance from nearest well------------------------------------------------- --------------_- -- Distance from nearest buildin g ---------- ❑ Distance to nearest lot line____________________ ------------------------------------------------------------------ Rvod I• g nd/or repairing (c cribe):_- ---- _-____n__ --------- ------- -----------------------------------------------------------------------------------•-•------ ----.-------•----------------------------------------•------------------------------=-•---•---------------------------..-..-------------- ------------------------------------------:-----------•-----------•- -----•-------------------------------------------------------------------------•---------------------------------------------------------- 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 rules and regulations of the San Joaquin Local Health District, (Signed)_ f (Owner and/or Contractor - -=, ` ,gJ r .. (Tills} ) BY: ----------------------- (Plot plan, Aing size of , location of system n re) tion to wells, buildings, etc., can be placed on reverse side). - ------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED Y ---- ------------------------------------------ - DATEREVIEWED BY ------- - - _-•SiILDING PERMIT ISSUED--------- ------------ --- ------------------------------------ DATEp ---------------------------------------------------- .. ------------------------------------ -- DATE-- Alterations and/or recommendations--------------------------------- ----------------------------------------------------------- -------------------------------------- -------------••------------••---------•--------•--- -- ------•- -_ ` ---- - --- ----------- _ ---- - .............. J : ------- - ---------------------------------------- -- FINAL INSPECTION BY:---- - ----------------------------------------- ------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American"Street 300 West Oak Street 132 Sycamore Street , Stockton, California 814 North "C' Street Lodi, California Manteca, California Tracy, California ES-9-2M , Revises 1-57 FT.CO.