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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 wit County Ordinance No. 549. JOB ADDRESS AND LOCATION. ___ _.__ _ -------------•--------------------------------------------•------------------------------ --------------------------------•-----------. Owner's Name-- ------ ----- ----------- Phone Address.---------- Contractor's Name d ,00.-10,/ ------------------------- ------------- ------ Phone----- ------------- --------------- ---- - ---------- Installation will serve: Residence Apartment House ❑ Commercial 14 Trailer Court ❑ Mofel ❑ Other ❑ Number of living units: ________ Number of bedrooms -------- Number of baths -------- Lot size ___20 '-x--yR---________ ----------------------- Wafer Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,) Clay Loam ❑ Clay ❑ Adobe L] Hardpan ❑ Previous Application Made: Yes ❑ No OR New Construction: Yes, No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_,�U7�-u�----Distance from foundation--l_U"'---------Material----ES No, of comar#mes � C -------•- ------pm ---- ------- ------ � qep --,__ ------_------ apacity-1-S- -----_-- 1 . Disposal Field: Distance from nearest well./�.-__-_Distance from foundation__-O��---------Distance to nearest lot lineZk -------- Number of lines--------- _ , __---------- -- - - -----Length of each line-----/-J.0 --- -------------- Width of french---19--''--------�------------ s Type of filter material _ _ Depth of filter material-,/.P--A-- Total length, I Seepage Pit: Distance to nearest we I______ ____________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___.._ f ❑ Size: Diameter-. + 5 t -------------- ...t.� �.. r Depth= Liquid Capacity----------------------------gals. + Privy' Distance -from nearest`well----------------------------------------------------Distance from nearest building------------------------------------------ El __.----_______________. __❑ Distance to nearest lot line- #----- Remodeling and/or .repairing (describe):- ' -----------------------------------•------------------------ = --------------------------------------------- 1 ------------------------------------------------------•---------------------_------- -• --------- ------•-------------------------- -------------------------•-------•------•--------------•---------------------• ---------------- .------------------------------------------------------------ - -- -------------------------------------------- I hereby certify that I have prepared�fhis application and thaf.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) g ) -- --- -�------------------------------------------------------------(Owner and/orContractor) By. , . k.---------------------------------------------------------(Title)--------------------------------------------------------------- (Piot plan, showing size of of, location of syste i relAion to wells,'buildings, efc., can be placed on reverse side). -o .. W FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- DATE_.e_'-$ --j- ------------------- - REVIEWED BY --------------------------------------------- ----------------------- ------------------------------------- DATE -------------- BUILDING PERMIT ISSUED---------- ------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:-------- J--------------------- ---------- ---"- -------•-- �F_- f • -----•----------- ----------------- 0;4 -------•--------------------------•--------- ------------------------------------------------------------- ------------------------------------ FINAL INSPECTION BY _ _ ,---------------------------- Date.-.-- qq 7 Date. y__ - -- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 Wast Oak Street 132 Sycamore Sfrset 814 North "C" Street ! `} Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revisea 1.57 EP.CQ. f