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APPLICATION FOR SANITATION PERMIT Permit No. ____________________ (Complete in Duplicate)V"j 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 application is made in compliance with County Ordinance No. 549. s JOB ADDRESS AND LOCATI N....-- --------- .-- - -- -------•--------------------r---�-/-----L--,-�------------------------ Owner's Name------- -- ----- -- ----------------------- Phonelk_7_--- Address--------.. _ // ��.. .r - -- - - - --- ---------------------------------------------------------------- ------ - - ---- - --- ------------------------------ .............,M . — Phone - ff = -----------------•------------------- /�L2� -Q�---- Contractor's Name._._.__ . ....�_____ . 17/0 { Installation will serve: Residence E-_A' partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ j Number of living units: :__ Number of bedroomr _ Number of baths __. _ Lotsize __ 7-_X_11_ __--__________________._ Water Supply: Public'system Community system Q Private r-1 "Depth to Water Table S_l'� ff. Character of soil to a depih-of 3 feet: Sand ❑ Gravel) ❑ Sandy Loam ❑ Clay Loarn ❑ Clay ❑ Adob,K Hardpan ❑ Previous Application Made: Yes ❑ No ; New Construction: Yes ❑ No,W FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: € (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) �n pti Tank: Distance from nearest welt_________________Distance from foundation--------------- -_--.Material------------------------------------------------- No. of compartments--------- ---------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- � po 'ield: Distance from nearest well___------------__Distance'from`foundation--------------------Distance to nearest lot lin e.__________._____ Number of lines----------------- ------Length of each line------------------------------Width of trench.---------------------------------- �G11 Type of filter material.._ _°-_ -._ _ Depth of filter material______________________Total length------------------------------------------ nZ Seepage Pit: Distace to nearest wells�lti-_ ____-Distan m f�undation/_�_�� ---___.Distance to nearest)of h Number of pits------ ------------Lining material ----Size: Diameter----"-"------Depth...13 --------------------- Cesspool: Distance from nearest well____-------------Distance from foundation--------------------Lining material------------------------------------ } ___Li Liquid Capacity gals. ❑ Size: Diameter--------------------------------------Depth---------- - --- - -a-------------- q p Y- ------------------------ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building -------------- ❑ - Distance fo nearest lot line--------------------x- =--- -------------------•------ -------------- ' Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------------------- • •-------------•----••-------••-------------------•---- -----------------------------------------••----------------------------------- ---------------------------------- r I hereby certify that I have prepared this application and.that the work will`be done in accordance with San Joaquin County ordinances, Stat laws, and rules-and regulations of the San4oaquin 'Local H alth Districf. (Signed)----- d�'' ---- { [�wner and/or Contractor) TitleBy:--------- - ------ ------- - - ------ (Plot plan, showing size of lot, location of system in relation we Is, buildings, etc., can be placed on reverse side). ) FOR DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY----- --- ----- - ---- ------------------------------------------------------------ DATE--------------- = REVIEWED BY --------------- DATE ' BUILDING PERMIT ISSUED--------------•------- ---- - --- - -_---- -------- --------------------------------------------- DATE---- I-- -------------------------------- --•----------- Alterations and/or recommendations:-__.__- __ ______________ ____t__.______ ___. ---- ---- ----------------------- ------------------ / - FINAL INSPECTION,-BY----- -- ----- ----•: ----- ---------=--------------------:-- _ Date___��(-. _. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 !`North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised 1-57 F-?-CO-