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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 Ordinance No. 549. JOB ADDRESS AND LOCATION- ------- OCATION_ -= � -_-�- ---' - � ��- n _ � Owner's Name----- '��' � -------------------------- Address -----------Address-----6f -- ---- ---- ------------ ------------------------------------------- ------ Phone----------------- ----------- ----------- Contractor`s Name------------- -__ _.__ ----- , ---------•----- ----------- --------- -- --------------- hone.--------- --- - P, Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _____ Number of bedrooms _Number of baths -----___ Lot size ---f _ _ Water Supply: Public system ❑ Community system ❑ Private 1� Depth to Water Table ./_0. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Y Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes FTA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: � a (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic^Tan *- Distance from nearest well ndation ----------------Distance from fou ______________-__ -.Material-------------------------------------------------- " No. of compar#menu Size_ ----------- ---Liquid depth.. Ca pacify y----------------------- Disposal Fiel Distance from nearest well_`-0------Distance from foundation---iyZ.---------Distance to nearest lot line..... Number of lines---------r------ Length of each line-------Ap-QWidth of trench.___ u Type of filter material. -: K_--Depth of filter material---/,�- _------_Total length------1sdt-v--•------------ --- Seepage Pit: Distance to nearest well--------------- _______Distance from foundation--------_-----------Distance to nearest lot line______.________. ❑ Number of pits----------------------Lining material----------------------.Size: Diameter------------------------Depth------------------------- esspool: Distance from nearest well---------------- Distance from foundation--------------------Lining material------------------------------ ------ ❑ Size: Diamefer------------------------- ----- Depth---------------------------------------- ----------Lpacit iquid Cay - __ gals _ Privy: Distance from nearest well------------------------------------------------Distance from nearest buildingl �� ❑ Distance to nearest lot lime---------------------------------------" ---------------------- Remodeling and/or repairing (describe)-------------------------------------------------------------------------------- -------------------------- --- --- -•----• ----- ---------- ------------------------q---------------------------------------•--------------------•----------------------- --------------------- - herebycertify that I have Y 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)---Y. .`�.: y-----------------------------------------------------"----------(Owner and/or Contractor) By:------------------------------•-•------------- ------ -- - -- --------- - ________ ____ - - - - - -- - - ---- - -----•- ----- -- ----------(Title)------- ---------- ------------ ----------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ------------------------ - - --------------- DATE REV ------- ------ 1 WED BY---------------------------------------�--------- - ------------ ----- ---- DATE---- �- ---- - - --- --BUILDING PERMIT PERMIT ISSUED_ - ---- ----- --�._--------------------- ----------- - DATE------ ------------------ J------------------------------ --------------------------Alterations and/or recommendations:___- ---------------------- FINAL INSPECTION BY------------- -- - ------------ --------- 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 7-57 F.P.CO.