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1 APPLICATION FOR SANITATION PERMIT Permit No. .___�� I (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 applicationi is made,in compliance with County Ord, ce N . 549. JOB ADDRESS AND CATlO I / ----- ---- Owner's Name- -------- -------------------------------------- - •_-'---_ ._� . Address__ 3 --- -------- -------------------- - one---------- Contractor's Name_______________ ____ ___ partment House ❑ Comme = Phone �- Installation will serve: Residence ------------ rcial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ___ .__ Number of bedrooms � r Number of baths ___� e ___--.�`TJ _� - Lot size Y Y ❑ ❑ p ---------------------- Water Supply: Public system Communit system Private De-0th to Water Table',$_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam r Clay t Y ❑ y ❑ Adobe[�ardpan ❑ Previous Application Made: Yes ❑ I No �ew Construction: Yes ❑ No ��HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool p�rmiffed if public sewer is available within 200 feet.) ! + It� Distance from nearest welL'_ - Distance from-foundation____.-_-;____--_�.Material______________________._____________No. of compartments---------------- Size _ --•- -.--Liquid depth----------------"-------- Capacity------------------------ Fi Fi d: Distance from nearest well_______________ Distance from foundation__________-___ l "- __._.Distance to nearest lot line.____________._. Number of lines----------------------------------Length of each line---------------------------_width of trench ------. Ype of filter material-------------------------Depth of filter material-----------------------Total length------------_---_---__---_ \` Seepag ct: Distance to nearest well_ ___ ___ Distance -m fo dation___ r V --" - ��___-__-.Di nce��o nearest lot lme__�(�--_-_-_ Number of pits...._-------------Lining material__ Size: Diameter______ -.--_.Depth---- _� -------- Cesspool: Distance from nearest well----------_------Distance from foundation_ ______._.__.___..Lining material__._-_____----------------------- EJ . Size: Diameter____.( f --- Depth -- ------- ---------- Liquid Capacity gals. Privy: Distance from nearest yell _ , Distance from nearest buildingk . ❑ Distance to neare�st lot line----------- - --- """ "" Remodeling and/or repairing {describe):_____.._.__r__.___ ------------------------------------------------------ 1 ---------------- ------------------------------------- - ------------------------------------ ---------------------------- 9 --------------------------------------------------------------------------------------•----------------------------------------------------- ---- I hereby cert' that I hay epared this application and that the work will be done in accordance with San Joaquin County F ordinances, State I s, d ru nd re ulation of the Sa aquin Local Health District. (Si ned 9 ---------------- wrier and/or Contractor) - -- -- ----- By%-------------------------------------------- - ------------------------(Title)---------- --------------------------- (Plot plan, showing size of lot, Iota on of system m relation to S. buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.-BY---------_:±"__---------"--_----_ _ -_ DATE REVIEWED BY ----- -------' -----------•-----------••---------- ------------------------ -------- - ------- -------- -----------. DATE---------- BUILDING PERMIT ISSUED------------------------------------------- ,-,� . �� -------- ----- ---------•----- ----• --------- - DATE- ------- --------- ---- Alterations and/or recommendations:__�__-_:___._______-___--- -- -- ------------------------------------------ p• ------------------------ -------- ------------ _ ,�,.�,,w - --- - _ .•. �° ., ------------------ --------------- - FINAL INSPECTION BY:------ . Date f- ----- --- SAN JOAQUIN LOC HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2KI Revised 1-57 F.P.CO.