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- APPLICATION FOR SANITATION PERMIT Permit No. .510_----- (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District forapermit to construct . This application is made in compliance with County Ordinance No. 549, and instal!the work herein described. JOB ADDRESS A LOCATION.-- > _S ��----` - -------------------------- Owner's Name--- 4--------------------------------------------------------------------------.- Phone Address — Contractor's Name-------------------------------------------------- ---------- ------- --------- ------- -- ------- -------- -------- ----- Phone----------------------------------• Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _lCommunify Number of bedrooms --/ -- Number of baths --- --- Lot size E]D �. Water Supply: Publi system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam EX Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes [] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 8 Septic Tank: Distance from nearest well---� Distance from foundation_-- �____--- -, J �� f Mater al No. of compartments_-" x Li Liquid de th_----'� .-___-_________Ca acit __ Size q p ------------ --- ! -- ------ - - Disposal Field: Distance from nearest well-----__'�-r_-_.Distance from foundation--- -"'`"-'� ".-.Distance to nearest lot line----_�____-. 5 Number of lines-------�-------- -_____ Length of each line----- __ �,��T'-�Q.Width of trench------ -��-- ------------ Type of filter material--- --------Depth of filter material--- Total length-__--_--. l_ --_----_ _ Seepage Pit: Distance to nearest well_"_____________ _ �� -----Distance from foundation--------------------Distance to nearest lot line__..-- ❑ Number Of pits----------------------Lining material-----------------------Size: Diameter----------.------------Depth--- ----------------------------- Cesspool: Distance from nearest well--------------- Distance from foundation_-------------------Lining material__-- -------------------------------- El als Size: Diameter--------------------------------------Depth----------------------------------------------------- Liquid CapacitY- ----------- --------- ---gals. Privy: Distance from nearest well------_--- --------------------------------Distance from nearest building ❑ Distance to nearest lot line____________--"------------- - �•\�j --------------------------- - - ------------- Remodeling and/or repairing (describe):________________ ---------•-----------------------•------------------- ---------------------•--------------------------------- ------------------------------- ----------------------- � ---------•------------------------------------------------------ ------------------------------•-------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------------------------------ ------- ---------------------------------------------(Owner and/or Contractor) By:---�"'-`--'— --- �-----------•-- ------- - ----- ----- - ---- -------------(Title)------------------------------------------------------------ -- (Plot plan, showing size of lot. Iota+ion of system in.relation fo wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- __________ ______________ ------- - -- ------------ ---------------------------- DATE--------- REVIEWED BY-----------""__-- _ - -- DATE---- ----- -- ------------------- BUILDING PERMIT ISSUED-------------- -- - --------------------------------- Alterations and/or recommenda+ions:-----_-_------_-- -_ _-" ----- DATE--- -------------------- ---------------------- ------------------------------------------------------------ ------------------------ - FINAL INSPECTION BY:. /----�� -- -� - 1 ------------------------------------------------- Date------------- ---?----��- = .-�------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street f32 Sycamore Street 814 North "C" Street Stockton, California 1 Lodi, California Manteca, California Tracy, California ES-9--2M Revised 1-57 FY CO.