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f 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 with CountOrdinance No. 549. 44� JOB ADDRESS AN LO TION_________ ` � ..... Owner's Name___ t a ----------- --------------------------------------- - Phone.- ---------------------------------- Address_.-------t'3a 'Y--- Contractor's --------------------------------------------------------------------------------------------------------- Prone ------------- Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I_____ Number of bedrooms _3-__ Number of baths Q-___ Lot size_ntV�r___.3__Q.)�____________________________.___ Water Supply: Public system ❑ Community system ❑ Private �j Depth to Water Table #.o_ ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam KI Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ , No IV New Construction: Yes X No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: '(No septic tank or' cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well ----Si 0 -----Dista ce from foundation ---I P-------_ Material--- ---------------------------- --------------------------No. No.of compartments------ .----------- --- Size- 4.3'r-6 ------------ Liquid depth ------ Y ---------------- Capacity_J?' ----------- � Distance from foundation_fo...____.___Distance to nearest lot liner_-_.___ro Disposal Field: Distance from nearest well_________ __ Number of lines--_.__ - d� �r ----- Length of each line____ ke - of trench ----- A�_______-_-----_--- Type of filter material__yr __ Depth of filter material_-�__�_-_______._Total len th___ � Q Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------------------- Distance to nearest lot line_________________ ❑ dumber 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 building __________________------______.__________- M ❑ Distance to nearest lot line Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------- ----------------------------------------------------------- . p -------------------------•--------------------------••-----------------------------------------------•----------------------------- -- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations o the San Joaquin Local Health District. (Signed) --7 - (Owner and/or Contractor) By:-------------••------------------------------•------------------------------------------------•-----------------------------------(Title)-----------------------=__------------------------------------ (Plot plan, showing size of lot, location of system in .relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ --------------------------------------------------- DATE-------------------------- ------------------- --- ------- REVIEWEDBY ---------------------------------------------- -------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE ---------- Alterations and/or recommendations: --------------------------------------------------------------------------------------- ----------•-----------•---------- . E ----------------------------------------- ------------------- --------- --•-------------------------------------------------------------------------------------•----------•-------------------------•---------------------- ------------------•------------------------------- --...-----t--------------------------------------- ---------------•-----•------------•--------------------------- --------------------------------------------------------------------------------------------------------------------- --------------------------------------- -------------------------------------------- -------------FINAL INSPECTION BY:. -- FINALDate SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i.300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M , Revised 1-57 F.P.CO.