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APPLICATION FOR SANITATION PERMIT Permit No. .. G,7--`---____ (Complete in Duplicate) Date Issued _ Applica+ion 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 County Ordinance No. 549. JOB ADDRESS AND CATION_ - - ------------- --- - ---------------- wner.s Name ------- -------- Phon -= ----------- Address____ oe Contractor's Name--- -••- �-----------•----------- ------ Phone--• - - ----------- ------------ ------------------------•--------- ��/'�� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-_- Number of bedrooms --.,7 Number of baths __ ___ Lot size 2-d _- 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 ❑ Adobq.� Hardpan ❑ Previous Application Made: Yes ❑ NOX New Construction: Yes� No E]TYPE OF INSTALLATION AND SPECIFICATIONS: / (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic T k: Distance from nearest well------ ._.__.__Distance from foundation------------------- Material _______ AtNo. of compartments_ ----Size-------------------- -----Liquid depth_ ------- ---------- . Ca Capacity isposal F• Distance from nearest well. ---- __Distance from foundation----------- Number of lines ---------Distance to nearest lot line----------------- --------------------------- geacne-----------------------------.Width of trench-------------------------_-- ype of filter materiaf-------------------------Depth of filter material------ -----.Total length------------------------------------------ Seepage Pit: Distance to nearest well_ t Distance fr foun ion - .- --�---____.Distance to nearest lot Number of pits.__-__ ___._ Lining material_ ,ize: iameter_____ _.___..___- VL Cesspool: Distance from nearest well __Distance from foundation______________-._- Lining material____-____________...________- a'• ----•- Size: Diameter ----------------- Depth----------------------- - - ------------Liquid Capacity ----------------gals. r Privy: Distance from nearest well________________ ___..Distance from nearest building--- Distance to nearest lot line____________________ -- ---- ---- - •- ---- Remodeling and/or repairing (describe):_____ w . -•-- - --------- --------------------------------- -- - ------ Z -- -•-- -- ------ -----• - --- ---- ---- - --- ----- ��(• I hereby certify that I haprepared this application and that the work wiil be done in accordance with San Joaquin County ordinances, State I nd d regulations of the San Joaquin Local Health District. (Si ned 9 �.--- - ----------------------- ---•- (Owner and/or Contractor) ------------------=-------- - By:. -- rte ----------------{Title) ` t. ------------------ ot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be aced n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------__..........________--;:ti - ��_ DATE--------- ------- ---------- REVIEWED BY -------------------- --------------------- ---------- '� J ---------------------------------- DATE------------- ----- ---BUILDINGPERMITPERMIT ISSUED------_------------------ ----------- - -------- DATE --------------------------------------------------- fierations an�dreco mendations:_-.. �� ---------------------------- J -------------------------- ---------- _rte.. ..... .. . ------------------------------------- c/ Fr"AL INSPECTION BY------------------- J Date 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 145445 A7W00D 12.54