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APPLICATION FOR SANITATION PERMIT Permit No. ,__� (Complete in Duplicate) Date Issued ---_zf 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. JOB ADDRESS AND LOCATION__ ? _ r , - -- ---------- Owner's Name --- • - ---------------------- ------------ --- -------------- -. Phone--------------------------------- Address---------- --- ----•--- - • -`--- ---- Contractor's Name- -------•---------------- •--------------- -------------------------- ---------------- ---- ------- ------- ----------------------------•-------- Phone__.-•-----------•----------------- Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Numberof living units: _ Number of bedrooms " --- - .2- Number of baths ❑ l__ Lot size A �` Water SuPPIY� Public system +Community system ❑ Private ❑ Depth to Water Table "�(d ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ � Previous Application Made: Yes [❑ No P��N ew Construction: Yes ❑ No FHA/VA: Yes ❑ No L4-1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) eep,fli Tank: Distance from nearest well-----------------Distance from foundation_----_-_---_-___-..Material__--_---_-----..".- ------------------------T No. of compartments---- -------- -- ----- Size--------------------------------- Liquid depth--------------------------Capacity _Dispo al Field: Distance from nearest well_---------------Distance from foundation_-_--_-.._----._"--.Distance to nearest lot line___--__.-_-____- �yj�/ f ' Number it lines---------------------- -----_Length of each line------------------------------Width of trench---------------- k Type of filter material-------------------------Depth of filter material----------------------Total length-----------•----------------_" Seepage P Distance to nearest well Distance from f dation__A- f D s ce to nearest lot line-: "-__-"-" Number of pits.-_--------------Lining ma#erial �� Size: Diameter_ ---------------Depth-- Jo�------------------------- -------- _ �f --- Cesspool: Distance from nearest well ___--___Distance from foundation----:__--_--__--__.Lining material- -_-----❑ Size: Diameter------ --------- -------- --------Depth----------------------------------- ------- PrivY Distance from nearest well-------------v --------- ---Li Liquid Capacity _ Distance from nearest building----------------------------------------- ----- __-----"--___---_ " ❑ Distance to nearest lot line -."� -- --- --------- 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, and rules and re ulations of the San Joaquin Local Health District. (Signed)------------- - -------- ------------------------------ Contractor) By%---------------------------------------------- __ I a - -------------------- (Plot plan, showing size of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY � APPLICATION ACCEPTED BY--------------------------------------------------------------------------------------------------- DATE REVIEWED BY ----------- BUILDING PERMIT ISSUED------------------------- DATE------------------- -- ------- ----- Alterations and/or recommendations: ----------------------------------------------=------------- -- -- --------------------------•--------------------------- --- - -----------------------------------•---------- -------------------------------------- ------------------------------------------------------- - - ---------------------------•--------------- --- --------------------------- FINAL INSPECTION BY:.-_- rjf Date . - --------------- ------------------•---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Sou+h American Stree+ 300 West Oak S+reet 132 Sycamore Street 814 North "C" Street Sock+on, California Lodi, California , Manteca, California Tracy, California ES---9-211 , Revised 1.57 F.P.CO.