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APPLICATION FOR SANITATION PERMITia3 9 Permit Na_ (Complete in Duplicate) / f 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. f JOB ADDRESS 'AND LOC TION / ---------- --- - ----------------- _ _ - ----------------.-.-_-_--------------------- Phone e------------------------------------ Owner's -------------------------------•---Owner's Name------------ ----------------- Address ------------ Address.----i-------- �--- -•---- Pho -Contractors Name--------------- I------_ ------- ---- Installation will serve: Residence Apartment House E] Commercial L] Trailer Court El Motel E] Other F] s Number of living units: . ------ Number of bedrooms � Number of baths __!_-- Lot size ______�--___�_-__f,— ----------------- Water Supply: Public system :,Community system ❑ Private ❑ Depth to Water Table4I_ ft. . Character of soil to a depth of feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay [j Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes E] N , FHA/VA: Yes ❑ N TYPE OF INSTALLATION AND SPECIFICA New (No septic tank or'cesspool permitted if public sewer is available within 200 fee+.) k: Distance #ramn earest well_________________Distance from foundation-------------------Material-------------------------------------.----------- No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-•-•------------------- S i Disposal Field: Distance from nearest well------------------Distance from foundation---------------------Distance to nearest lot line----------------- Number ---__-_.___.____ _ s--------------- -------------------Length of each line------------------------------Width of trench----------------------------------- d Tlu e of filter nmaterial-------_---__ ._______Depth of filter material-----------------------Total length________.__________---.________--_`_-- Yi� -pistance fr foundation___ ________________Di tanc to nearest lot Seepa a Pit: Distance to nearest well__ _ �� a INumber of pits-------_/-----------Lining material___--_ _._. - _Size: Diameter___..._----__Depth_- ---------------------- Cesspool: _________--_Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material------------_______.____-____-----. ❑ Size. Diameter!!----------------- ------------------ Depth--------------------- ---------------------------Liquid Capacity-- --------- ----------gals. Privy: Distance fromllnearest well-------------------------------------------_---_Distance from nearest building----------------------------------------- - ❑ • Distance to nearest lot line------------------------------- ---- ----- -------------------------�-•---------=------ ------ ------------------------------------- e �. Remodeling and/or repairing (des icribe):------ ----------- ---------------- �--^_-------------- ----------------------- = --------------------:--- ---- -----------------------------------------------------------------------•------- --------- ----------------------------------------------------------------------------------------------------------------------------------- ------------------ ------------ ------------------------------------------------------------------------------------------- - 1 hereby certify that I have prepared'this application an t the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regula ' s o the S J quin Local Health District. (Signed) owner and/or Contractor) By:-------------------•--•-•*----------------------------------------------- ---- ---- --- ----- ---------- -- ----------(Ti+le)-------- -:----- -- - -- ----------------------- [Plot plan, showing size of lot. location of system in relation to wells, buildings, , can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY -------------------- ------------------ ---------------------------------------- DATE-TI --------------------------------------------------- •_ REVIEWED BY----------------------------- .. { - DATE �. BUILDINGPERMIT ISSUED---------------------------------------------------------------------------- ------------------------- DATE----!:--------------------------------------------------- „ Alterations and/or recommendations----------- --------------------------------------------------------------------------------------------C-1 ----------- -- --------------------------- ------------------ ---------------------------------------------------------------------------•---•---•-----------------------------------•-------------- ----------------------------------------------•---------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------- ------------------------------I---------- ----------- ---------------- --------------------------------- --------------------------------------------------------------------------- FINAL INSPECTION Date--- ----------------------------------------- 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.