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APPLICATION FOR SANITATION PERMIT Permit No. 5�b (Complete in Duplicate) 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. JOB ADDRESS AND LOCATION---_ - ,;?/ -------------- --------------------------------------------- -------------------- ---------- Owner's Name--------- - -- -- --------- ------ Phone------------- - -- - ------------------------------ Address------------- - � ----------------------------•----------------------- ------------ -------•---------------- Contractor's Name------------- ----- ---------r Phone ------------------------• --------------- ------------- Insfallaflon will serve: Residence�parfinent House E] Commercial ❑ Trailer Court ElMotel F-1OtherElNumber of living units: --- --- Number of bedrooms ---X Number of baths --1-- Lot size ---_WAP _ __ _____-.____ Water Supply: Pblicsystem Ppy� uy Community system ❑ Private ❑ Depth to Water TableY,;ift. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A--`H`ardpan ❑ Previous Application Made: Yes ❑ No PR' New Construction. Yes ❑ No R�' FNA/VA: Yes ❑ No [ "� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) e F f lit Ta A: D�stance from nearest wellepti Tank: Distance from nearest well -- Distance from foundation----_----..--------.Material----------------------------------------- No. of compartments--- Size Liquid depth Capacity -------------------- isp :W o al FieldDistance from nearest well.---_-_-.------Distance from foundation---------- --------Distance to nearest loft line----__-------.--- �� n 1 fi Number of fines--------- ------------------- - Length of each line----- - rTf- �� Width of trench..---, -----.-____ - --------- Type of filter material/ Depth of filter material--_f - ---,-----Total length----- --�---_----------------- r ' � eepa a Pit: Distance to nearest well----------------------Distance from un tion--��...:-._..Distanc to nearest to line��-_---- r� Number of pits------4-----------Lining material- _" Diameter-_L7J-----------Depth_ ° ---------•- Cesspo : Distance from nearest well-----------------Distance from foundation--------------_----.Lining material.-------------------.---------_------ \� ❑ Size. Diameter------------------ --------------------Depth--------------------------------------- - ----- --Liquid Capacity-------•--------------------gals. Privy: Distance from nearest well---- -----------------------------------------__Distance from nearest building.--_--__-------_-_-----_----------_-__-_. ❑ Distance to nearest lot line--------------------------------- Remodeling and/or repairing (des cribe):-------------------- vK� Y \ ------------------------------------ ----------------•--------------------- ----------------...-_--------------------------------------------------------------------•----------------------------------- ------------------ 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 regula 'ans of the San Joaquin Local Health District. (Si ned ig ---- ! ld .t -e��.'r''.....v----------------t ontractor) By:-------------------------------------------- ------ `-------------------------- Title----- ( - f----------------- {Plot plan, showing size of lot, Iocatiq f sys+em in relation to wells, buildings, etc., can be placed oh reverse de). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------- ---------- ----------------------•-------------------- DATE REVIEWEDBY--------------------------------------------- ----- ---- --------------------------------------------- DATE----------------- BUILDING PERMIT ISSUED--------------------------------- - --- - ------------------------------------------- DATE--------------- Alterations and/or recommendations:----------------- -- ----- -- ----------- --------- - -- � r e -- - - ----------- ------------- -------------- ---- --------- -----• - ----- FINAL INSPECTION BY --- ---- �z - � -- -----�-------- -- Date-- ----------------�- --�---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F,P.CO.