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�r APPLICATION FOR SANITATION PERIVI'7�'T Permit No. s [Complete in Duplicate / Date Issued f Application is hereby made to the San'Joaquin Locai Health District for a permit to construct and install the work herein described. This a�plica-fiori is made-in compliance with County Ordinance No. 549, JOB ADDRESS AND L A ION_S�__ -" ... Owner's Name A�_-- ------- Phone ----------------------- -- ---------------------- Address-•--------------- 1 Ar. __ .. Con#rector's Name = 1410,-- --•--• ---- ----- Phone- - ------------------------ -------------------------------------------------------- Installation will serve: Residence ( partment House E] Commercial ❑ Trailer Court ❑ Motel -❑ Other ❑ Number of living units: -4--- Number of bedrooms,-3-._ Number of baths ---I-- Lot size - _ ✓ . a� Water Supply: Public system E] Community system �rivate E] Depth to Water Table___._-__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ["Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ 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--------.--------Distance from foundation--------------------Material No. of compartments------- --------=--------Size-------------------------------Liquid depth--------------------- CepacitY...................... Disposal Field: Distance from nearest well-----------------.Distance from foundation--------------------Distance to nearest lot line- Number of lines------------------------------------Length of each line------------------------------Width of trench---------------.--------_-__-- Type o filter mi terial_---_________--------"Depth of filter material----"------------------Total length--------------------- -----------•_._ ------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearestIo# line___..__._____.-__ ❑ Number of pits-'--------------------Li nq material-----------------------Size: Diameter------------------------Depth----------- Cesspool: Distance from neares#_v ell-e-vkzta4--Distance from foundation----�'�'___.__:-Lining material"-- -ter__-- ,r ® Size: Diameter- - , �----------------- ---Depth-------(-------------------- ---------------------Liquid Capacity,---Ro-Z7--- -gals. Y Privy: Distance from nearest well"""_ ------------------------------------Distance from nearest building ❑ Distance to nearest lot Jine-------------------------------- --------------------------- - - - -------------- r •be). ""_ - - - - ----------- ------ f �. c ------- ----------------- -•-------- --------------•----------•------------------------------•--------•----- ----------------•------------------------------------------------- f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 4 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. I " --- ---r r By:.------ ---------------------- _ iv ner and/or Contractor --:. [Title)-:------ (Plot plan, showing-size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I © PA MENT U E ONLY APPLICATION ACCEPTED BY____.__ r' . . 1 �- --------- DATE_"_.A� - .:_,?_ -- - -------- .. VIEWED BY-------------------------------------- - DATE------- BUILDINGPERMIT ISSUED---------------------------------------------------------------- ------------------------------------- DATE Alterations and/or recommendations:_______________________ ___ -------------------•--------------------•--- ---- - ------------------------I----- -------------------------------------------------------------------------------------------------------------- l FINAL INSPECTION BY:------- = Date---- � � ----------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California6 R Lodi, California Manteca, California Tracy, California E1 -9-2M Revised 1-57 F.RCO.