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APPLICATION FOR SANITATION PERMIT Per l0. . _7_®• ------- (Complete in Duplicate) y �•'�'Defe 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 No. 549 JOB ADDRESS AUD LOCATION.__a, ------17----------- -------- ----------- f.&'Iext------------------------ -------------------------------------------. Owner's Na a -- -- ---------- ------- ----•----•----------- = -- ------------------------------------ Phone--------_----- Address -•--•-- - Address--- - ------ ------moi'" _.1----- --- ------ ---- _-. - Contractor's Name---------------------- - - �-----------------------__------------------------ Phoned .1407- Installation will serve: Residence E<Apartmen+ House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other'❑ Q , , Number of living units: _1___ Number of bedrooms .v2-_ Number of baths _ __ Lot sfize ___________ Wafer Supply: Public's.ystem Community system ❑ Private ❑ "Depth to Water Table __ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No [PNew Construction: Yes ❑ No g?'_FHA/VA: Yes ❑ No [�f� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) ep 'c,Tank: Distance from nearest well_________________Distance from foundation-------------------- Material____-_-________-______-____-_--________-____-__. No. of compartments---------------------------Size------------------------------•Liquid depth--------------------------Capacity-----------_ ----- Disp sal eld: Distance nearest well --- Dislance romdation---------------------Distance to nearest lot line_____`__________ Nurbeof lines t ---- - - Length ofline ----Widh of trench----------------------------------- Type of filter materiaf-----------------------__Depth of filter' 'Material_-_-_____-__'________Total length----------------------------__"_________-_ -- . ° 10 .. Seepage it: Distance to neares# well _'lJistanc om fo ndation___ _______ _____Distance to nearest lot line _________-____- Number of pits----,l--------------Lining materialSize:'Diameter___ __-_ Depth . ----------- Cesspool: Distance from nearest well_________________Distance from foundation________#_______--Lining material__________________-____-____----__--. ❑ Size: Diameter-------I----- Depth_----------------------------------------- --------Liquid Capacity----------------------------gals. Privy: Distance from neo est`well_____________________________-___--------------Distance from nearest building.-________-___________________-_______-_- V1 ❑ Distance to nearest lot tline__----------------___^ - k a - e Remodeling and/or repairing (describe):'----- ---------------------------------------•--•-----------•-----------•-------------------------------------•----•------•-----•-------------- l hereby certify that I have prepared this application and that the work will,be done in accordance with San Joaquin County ordinance , State laws, and rk and regulations of the S Joaquin Local Health District. (Si ned 9 )- /_x ---------------------------------------- Owner and/or Contractor) e , B (Piot plan, showing size of lot, location'of system in lation to wells, buildings, etc., can be placed on reverse side). FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------ ---- ---- ---------------------------•--------------------------••--- DATE------ REVIEWED BY------------------------------------ ------ --��------------ ----- DATE---------- --�� ----------- ----------------------------- BUILDING PERMIT ISSUED------------------------------ ---�---- ' DATE_--------------• -----11 ---------------- -------------------------------------- Alterations and/or recommendations---------- ------ `-------------------------=------------------------'----------• ----_----------------------- ---------•-•-•------------------ ---------------------------- FINAL INSPECTION BY:---------- -------- ------- Date------ = (-- -------------------"----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21v1 , Revisea 1-57 F.P.0O3