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APPLICATION FOR SANITATION PERMIT Permit No. (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 Ordinanc No. 549. JOB ADDRESS AND LP--- ------------------------------------ ION-- -- Owner's Name-------- ---------- ------ - ------------------- Address---------_ ------------------Address------------- ----------------------------------------------------------------------------------------------- Contractor's Name------ ---------------- -------------------------------------------------------------- Phone----------------------------------- Installation will serve; Residence partment House E] Commercial E] Trailer Court �ofel [] Other E] Number of living units-. Nu`mbe'r of bedrooms ❑j- Number of baths j Lot size -------------------- Wafer Supply: Public system 9TOO'Community system El Private [] Depth to Water Table'ft. Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E] Clay Loam Ej Clay [] Adobe 2� Farclpan E] Previous Application Made; Yes E],No � New Construction: Yes Ej No ®`FHA/VA: Yes [-1 No [�J— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Ta4-. Distance from nearest well-------�--___Disfance from foundation__________________Material------------------------------------------------- i No. of cympartmenfs---------------------------Size----------=---'---------------Liquid depfh---------------------------Capacity----------------------- A Disposal Field: Distance from nearest well------ -----Distance from foundation--:/---____-Distance to nearest lo I' Number of lines____,4 / . . — -le t ine ---- --------4-40-----------Width of trench------ZV_" Type of filter m- -------------1.A I 0_0-------- -------------------- �,ength of each line .............. Wepth of filter material----- length-------irr_ Seepage Pit: Distance to nearest well-------—--------Distance f m fov,ation----J-0------ii t9jce topparest ]of ng material_jO; Size: Diameter.--m Nu�nber of pits------1Z-------- .......Z-47---- -------- f. . i Cesspool- ',Distance from nearest well_________________Distance from foundation.-.------------------Lining material__-___- ---------------_-___________- Size: aterial-------------------------------------- Size: Diameter----I- --------------------------- _-Depth------------------------------ ---------------------Liquid Capacity----------------------------gals. Privy; -1 Distance from nearest • well---- ------------------------ ------ --------Distance from nearest building_______-_________________________________. ❑ i Distance to nearest lot:'line----------------------------------------- - ------------- -------------------------------------------------------------------------------- Remodeling and/or repairing pairing (describe):---- ----- -------- --------------------------I--------------------------------------------------------- ------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------I-------- I---------------------------------------------------------- ----------------------------------------------------------------------------------------- ---------------------------------------%--------------------k-e----------------------------------------------------------------------------------------------------------------------------------- -------------------------- 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 arulesa regulations of the San Joaquin Local Health District. (Signed)__ --� ------------------ J_ 00--- --- - ------ -----------------------I------------- ---------------(EWwm-mrfd�sr Contractor) By:------------------ ------------ -------- - ---------------------------(Title)-------~_ A4400_w!t--------------------- 7-----------! (Plot plan.-shov;ing size of lot;location-o stem in.relafion to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- `- ------------------------------------------------ REVIEWEDBY_7 -------------------------------------------------------------------------------------- DATE--------------- _ $UILDING ATE------------------------------ BUILDING PER I" MIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------- Alterations and/or reco mimendatioft:------------- --------- ---------------------------I-------------------------------------------------------------------------------------------- ------------------------------------------------ --------P -T- jj--------------------;Z-s----------------------------------------------------------------- ---------------------------I---------------------------=- ------------I--------------------------- --~------------ - ----------- ----------- 7-------------------------------------------------------------- -----------------------------------------cmv_ - -------- K.---------------------------------.---------------------------------------------------------- ---------------- ---------------------------------------- -------I- -------- -------------------Z- ---- ---- ---------- - ------------------------------------------------------------------------------ --------------------------------- FINAL INSPECTION BY- - --- -- ------------------ ---------- Date------ - iC 1------------------------------------------ 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-9-21x1 Revised 1-57 F.PCO.