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" 1lPermit No. '`--- A �IL�CATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued Application is hereby made to the S In 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. _?919 ----------------------------------------------- Phone--------------- ---------------------------------------- JOB ADDRESS AND LOCATION-------- _ ----------------------------------- -------------------------------- Address .----------•------------------ Owner s Name___,., -- -• --- -- -•-•-- --- ---------------- --•--------- Address---- ------------ / Contractor's Name----------- --_-------- _ _ Installation will serve: Residence ❑ p Motel Other Apartment House ❑ Commercial ❑ Trailer ❑ ---- Lot size ---�-�--- .... - --•�-`�-t----------------- Number of living units: ---�-_ Number of bedrooms _/__ Number of baths _� h Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 3p- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ . No V New Construction: Yes ❑ No rg FHA/VA: Yes ❑ N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) --------Distance from foundation--- _6.-------.Mate/iai---- ------------------•-- ----- Septic T k: Distance from nearest well __-_ ._. J No. of compartments--------4 ------------Size---4---�°--.[___2-6-----.---Liquid depth_.._.1.4 ---------Capacity -- ------- Disposal Field: Distance from nearest well--7-A_!__----Distance from foundation__a2'0-/------Distance to nearest lot line----- Number of lines________________ Length of each line____j_Q_'_____7�-------Width of trench_____z__ _.--------------- Type of filter materiai___,�t-_. _ _. Depth of filter material____ "_--.Total length____.____ _..a___________________/_ ._. � 1 --- Seep it: Distance to nearest well__jte_rV___-_--Distance from Dundation___S�-_____- istance to nearest lot line--------------- V •� Number of pits------ ------------Lining material--- ------- ---.size: Diameter_-- _. ._--_----_--Depth--_ 3--- Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------___a__l_s._. Size: Diameter------------------ ---------- ❑ ---------Depth------------------------------------- -------------Liquid Capacity----------------------------g Privy: Distance from nearest well---- --------------------------------------------Distance from nearest building--------_______________------------------ 'h ❑ ----•----------------- ----- --------------- Distance to nearest lot line_------------------------------------------------------------------- ----- Remodeling and ------------------------------------•-••---------------•-----------•---•-------•------------- /or repairing (describe)------------------------------------------------------ ------------------------------------------------------- ------------•-----------------------------------------------------------•--------------•------•----•---------------•-------•--------•----------------- I hereby c i that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S a la s, and r les and regulations of the San Joaquin Local Health District. ------------------------------------------- --------Owner and/or Contractor) (Signed) ---- __ {Title)------ - -------------------------------------------------- By(Plot plan, showing size of lot, location of sy tem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------•-- --- ---------------------------------------------- DATE------------------ -------------------- REVIEWEDBY------------ ----------------------------------------- - ------\------------------------------------------------------------IDATE--------------t"�----•---------------•--------------- BUILDING PERMIT ISSUED---------------------------- - - DATE-------------` -------------------- ------------------- Altera-t-i-o--n--s- and/or recommendations----------- - --- = ---------- --------------------------------------- -------------- `� 3 -------------------------- - --------- --- -•-- ----------- �.. FINAL INSPECTION BY: ��--- ----------- ------ - 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 , Revisea 1.57 RP.CO.