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APPLICATION FOR SANITATION PERMIT Permit No. ________ (Complete in Duplicate) Date Issued Application is hereby made to fhe San Joaquin Local Health District for a permit to construct and i This application is made in compliance with County Ordinance o. 549. ns#all the wort herein described. JOB ADDRESS AND ATI N__ -------- Owner's Name------ . r ----- Ph - - Address ----------------------------- --------- ----- , --------------"-----------------------------------• -------------- Contractor's Name------------ "r�tiVl/r/ -------------- ------- Phone Installation will serve: Residence p ❑ + [t}'�A artment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _/__- Number of bedrooms _ ._'Number of baths __/_ Lot size _00 Wafer _ __ - Wafer Supply: Public system ('Commun'ify system "❑ Private ❑ ' Depth to Water Table ft/ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g?`Pardpan ❑ Previous Application Made: Yes ❑ No k'New Consfruction: Yes A o ❑ 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-_�_,417_4Distan,c{e--from foundation__.IM_-_-_-.Material-__ - -- No. of compartments--{ ----------------- Size__1 -""X�a ---Liquid depth-__� _ ----____Capacity _ E P Y ------C�- Disposal Field: Distance from nearest well-P /.Distance from foundation__ `�r � _ _____.-__.Distance to nearest hot line_____`""""-. Number of lines /-------------- --------Length of each line___, -- ------- of trench.._,-- Type of filter material--/ , i �-6 " ____ Depth of filter material__? r-------Total len fh,___. r -�y�� g -rte ---------------•------- Seepage Pit: Distance:to nearest well__--- /I�t_LZ- Distance from foun ation___ s ___.__.Distance fo nearest lot line ------ Number of Pits__________.____---Lining material_ __;'�� , -- -_-- -_- --Size: Diameter__.. ---------Deptn__-----. __ ------------- 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 ❑ Disfance'to nearest lo+ fine___________________ Remodeling anti/or repairing (describe;-------- ---- -- -- - "" - ------------------------ ----------------------------•------------------- ------------------------------------------------•--•------------•---------------------------------------•------------- - I hereby certify thaf I have prepared this application and that +he work will-be done in accordance with San Joaquin County _ ordinances, State laws, and rules and regulations of the San Joaquin Local ealth District. (Signed) ;� -- `'IB�o Contractor) -- --- -------- -- - -- ----------- -- _ $Y:--------------------------------------------- -- r �=---------------------(Title} - .7 (Piot plan, showing size of lot, Iota ' of system in relation to wells, buildings, etc., can be placed on reverse e)-FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y-------------______"" _"-_ -_--- ----" - -" REVIEWED BY DATE --------- -------- -------- - ------------------ --- DATE--------------- - -- ---------------------- -------- %, ------------------------------•------- UILDING PERMIT----I--S-----S---U---E-D----------------- SSUED - ---- -------- DATI= -----------------------------------:-- ------------------.-.-.-.-.-.--. Alterations and/or recommenda+ions_________________ __'�- --'?*----- -"------------------------ _ _ --- -----•---- -------------•-------------- f ---------- FINAL INSPECTION 8Y: -- ----------------------- ------ Date---- -------------- SAN --------_--_SAN JOAQUIN LOCACHEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M . Revised 1-57 ERCd.