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APPLICATION FOR`SANITATION PERMIT Permit No. ._fl.. ! (Complete in Duplicate) / Date Issued _V 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. � • O JOS ADDRESS AND CATIN / = :. Owner's Name---- ---- ._----- "... . _ Phone - -- ---- --� ----- --- --------------- Address----------------- -------- •-•--�--- -------- --- -- ----------------- ------ ------------ --------------------- •--- -� �"/ Phone-- ---- --- •--- Contractor s Name------ � - - � ---- - --- ------ --- -- ��-2 Installation will serve: Residence Apar ent House ❑ Commercial ❑ Trailer ourt ❑ Motel ❑ Other, ❑ Number of living units: __ __ Number of bedrooms__ Number of baths _-__ Lot size ._.�`�UI --------------------••- -Community system EI Depth to Water Table Water Supply: Public systemt h Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adob Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YesX No ❑ FHA/VA: Yes ❑ No L ` TYPE OF INSTALLATION'AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----------- Distance from foundation--------------------Material _______-----__-"_"_____-______________--_____. No. o€t'compartments------ -------------------Size--------------------------------Liquid depth-----------------"--------Capacity-------------=---- Disposal ield: Distance from nearest well_________________Distance from foundation:--------:_________Distance to nearest lot line_ -------.--------- tSee:p Number of lines------ -------------- ---------- :Length of each line-------------------- ---------Width of trench------------------------------•--- Type of filter material_________________________Depth of filter Material-- ________________Total length_______.-_-________________________--____ ge Pit: Distance to nearest well--;-,If from f clation d__'�'...Dista«e to nearest lot line_ "4__. �` Number of pits-------l---- --------"Lining materials* Size: Diameter Depth a`� Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material------------______ _______---------- Size: _____ - Size: Diameter-------- -==---- ------------Depth----=-=----------;------- --- ----- --------Liquid'Capacity----------------------------gals. #P Privy: Distance from nearest-well--------------- -------------------------------Distance from nearest building----------------- --------..--------------- ❑ s Distance to nearest lot line „-- - �.� _- -------------------------- ------"------------ e n� F Re -modeli r-repairing (describe):----- .�- s- ------ --- --- - ---- _ -----•------------------------------------------------------•-----------•--------------------------------------- ------------------- - r ; I hereby certify that l have prepare this,appli tion a d that he work will be"done in accordance with San Joaquin.County ordinances, State laws, a rules a r ulations o he S Joa n Local Heal District. v I ------- -----(Owner d/or Contractor) (Signed)•- I By:.... � (Title: - ------------- -------------------------- -- (Plot plan, sh wi lot, ion of system in.relation to wells, buildings, etc., can be p aced on reverse e). FOR DEPARTMENT USE ONLY � I APPLICATION ACCEPTED BY------------------------- -- — -- ------------------------=------------------------- DATE-------------- - "6 (� 'DATE------------ - ------- --- ----------------- REVIEWED BY--------------------------------------------------` - - ----------" BUILDINGPERMIT ISSUED-------•--=-------------------------------------------- ----------------------- ------ DATE------ ------------------=----=---------=------------------- .. Alterations and/or recommendations:------------_---------p- ---------------------------- ------------ L1+F«.C_ --!�-�"Q--- ---- - ----- -----'`''� �- �== --------------- --------------------- - -------------------------------- --------------------- ---------------------------------------- ---------------------- -------------- n --- ------------------- ----------•-------------•- -------•--•-------- ---------- __ ---------- 1T fi r' = = f 1--•------- -��-`--------i-X----7"--— ----•-------------------------------------••-------- .; 1 INAL -INSPECTIO BY:_ f - r Date------1i�---- --�----�� = 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 Revised 1.57 F,P.CO.