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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 applicaficin is made in compliance with Coupy Ordinance No. 549. JOB ADDRESS LOCATI . , f` Owner's Name_-__-- ` --- --�---- " hone----- -------------------------- LOC ------ ---' -------- Contractor's Name_ ------------------- - -•--------------------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trarriler Court ❑ Mo el [] Other ❑ Number of living units: -1----- Number of bedrooms _-k- Number baths -1----- Lot size ___ -/--� --------- -•---------------------- Water Supply: Public system ❑ 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 O/Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes R-"'No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: #' f (No septic tank or cesspool permitted if.public sewer)is available within 200 feet.�� Septic T nk: Distance from nearest welL �' Distancf fr .fo anon- �-- _-__--.Mater a---_.__ I t� --- -- ------ No. of compartments . S ze ..ti x Liquid depth CapatitY Q f ---- Dispos Field: Distance from nearest welll5Distance from foundation-1 _ 7►'�"Distance to nearest lot lin _ "/J - ;, ,� -------- Number of lines______ _ _ ___ ______Length of each lineal)-- ms s Width of trench of filter materi � �D£pth of filter material-----_j. ------------Total length---------/.�0----- ---------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line--.-.-_.--___..- ❑ Number 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--__.__------__--------_-.-----------__--. ❑ Distance to nearest lot line------------------------------------------------- ----------------- a Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------ - ------------•---•----------------------------------•-----•----•-------•------ ----••--••------------------------------------ -----------------------------------------•----------------------------•-----------------------------------------------------•-----------------------------------•-------•----------------•------------------------------- ------------------------------------------------------------••----•---------------...------------------------------------------------------------------------------------------------------------------------------ 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, apd rules and regulations of the San Joaquin Local Health District. (Signed)—-- -Y__------ [ / 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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B r ---_- ------------------ --• __ _ S� REVIEWEDBY------------------------- ------------------ .-------------------------- ---------------------- ----- DATE. BUILDING PERMIT ISSUED ------------- ----------------- ----------------------------------------------- ---------- DATE-- Alterations and/or recommendations-------------------------------------- -------------------•-----------••------------ ------------•--------------------------------------------- ----------------------------------------------- Date_ FINAL INSPECTION BY:____i 'f / . I --------- 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-9-2M , Revised 1-57 F.P.CO.