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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ .�._;.�2._,._.._-_, Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hQrein described. This application is made in compliance with ounty Ordinance No 549. JOB ADDRESS AND LOCATION-- -------9-_` � -�81 Owner's Name------ � -------_ -------•---- ----------------------- -- ------- ---------------- - Phone Address---------I¢ -j-- ------ Contractor's Name---------------` ---- -------- - �Pll `__ Phone------------------------- --------- Installation will serve: Residence @a-"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __i Number of bedrooms S--- Number of baths -_, •_ Lot size ------------------------------- Water __ _ _Water Supply: Public system ❑ Community system V?'rrivate ❑ Depth to Water Tablej ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ 0ay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No P��New Construction: Yes ®moo ❑ FHA/VA: Yes 9?--No ❑ ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well -Distance [J� � from foundation___ p________-Ma-teriai---6 e.--- / _ _-- ._No. of compartments------ __________________Size___� -ALiquid.dePt _�� --- Capacity--- Disposal apacity___Disposal !b Field: Distance from nearest well_1 -bistance from fours o _2_ istance to nearest lot line__- [l� Number of lines_'-_ - .-__ _Length of each .ine_: _ _ , idth of trench_____ol X.. -____________._ '6N `. Type of filter material-_ _ p ! length De th of filter material _______,lBfd_______________________ Seepage Pit: Distance to nearest weli__'`_� _Distance from fo dAtjonr_'_`" ._-_..Distance to nearest lot line__/Q:_,_ ITS Number of pits-:--_A'---------Lining material_/� Size: Diameter-----1,3----------Depth_____ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material---------.-.___ _ _-.��___. ❑ Size: Diameter-------:--------------,-------------Depth--------------------- _-----------------------------Liquid Capacity-------------- -------gals. i Privy: Distance from nearest well________________________________________________Distance from nearest building____-___________-_-___. El Distance to nearest lot line-----------_ Remodeling and/or repairing (describe):--------- --eAor r __________ __________________________________________________________________________________________________________________________I____________---___________-_-_____________--_________________--_-__-_____-______-____ R •- - _ - _- - _ _ _ _ _ _ - - -------------------------------------------------------------------------------------------�_•----------------------'-.-------------- 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)-------------------- ---- -- ------ ---- --- - --- ------------------(Q..a �-awd or Contractor) By:-------------- ;._... ----------- -----------------------------------------(Title)---` --------------------------- (Plot plan, showing size of lot, locatio system in relation to wells, buildings, etc., can be placed on rever side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------- - -------------- ------------------------------------------- DATE--------- � --- ------------------------------------------------ - -- ----------------- ----- REVIEWEDBY--------------------------------------------- -- - ----- ---------------------------------------------------- DATE----------- ----- -------------------------------------- BUILDING PERMIT ISSUED-------- - ------------------------------------------------ ------------ DATE--------------- --------------------------------- Alterations and/or recommendations: ----------------------•-•-------------------------------------------------------------- --- -------------------------------------------- ---------------------------------------------------------------------------------------------------------------------•=--------- ------------------------------ FINAL INSPECTION BY: w'" _._. Dater- -- --------- ------- --------------------- SAN JOAQUIN LOCAL 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-4-2M Revisea 1.57 EP.CO_