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APPLICATION FOR SANITATION PERMIT Permit No. ......... (Complete in Duplicate) Date Issued ----- Application is hereby made to the Son Joaquin Local Health'Disf rict'f6r a permit to construct and install the work herein described. This application is made,in-complianc%W ounfy Ordinance No. 549. 2 JOB ADDRESS AL)DCATI ---------- f- ------------------------------------------------------------------------------------------------- - ----- 11,11... ----------------------------------- Owner's Name---- ----- --- --- -- -- ---------------- -I-------------------- ------------ - --------------------------------------------- Phone--------------- -------------------- Address------... Contractor's Name---- -- - ------- ----- -------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: esi nce Apartment House [] Commercial E] Trailer Cturt 0 Motel [-] Other El Number'of living units: Z Number of bedrooms _*_ Number of baths _Z--- ----- ------ Wafer Supply: Public system _�/Commun'ity system E] Private F] Depth t Water Table -------- ft. Character of soil to a depth of-3 feet: Sand nd Gravel E] San'dy-Loam -clay Loarri.E] Clay E] Adobe L],, Hardpan E] Previous Application Made: Yes [] No �114PN'ew Construction' N Depth ❑ FHA/VA: Yes E] No E9" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic 'ank: Distance �ron nearest well "_:bi __ sfance from foundation---- , feriai----&-----------_--_ ---------------•----,------- No. of compartments------- --Z-- !�, ----- --_ ,Z ---Liquid depth----------------1111---------Capacity---t;;�+O_OF... Disposq4"Field; Distance from nearest we44144 -Distance from foundation Distance to nearest lot linip. Number of lines --.=L ---------- -----Length of eachlrr ine_________. _ _0------- 5?r ----- Width of trench------ J�- -----r Type of filter material"__. ?W_ ��__ epth of filter length_____________ 'O---_--_-_--__ Seepage _'O-------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------_Distance to nearest lot line--.______________ 94 ElNumber of pits----------------------Lining material-----------------------Size: Diameter___:___------...______- Depth_.-_-----------____-___________ Cesspool: epth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------lining material------------------------------------- El Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity-----------------------------gals. Privy.- Distance from nearest well-------------------------------------------------Distance- from nearest building___._.___---_------_________________.___.. ❑ Distance uilding----------------------------------------- Distance to nearest lot Gne- -------------------------------------------------------------- R or repairii-In scr ncl/ 'ad i b -- - ------------ ----C_�<------ tn --yJAj---------- _C_ -- ---------------------------------------------- ----- --------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- ------------- I hereby certify that I 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)---- Zwex---- ----- -----------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:-----------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------- -- ---------------- (Plot plan, showing size of lot, location of system inrelation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By ----------1-1--------------------------------------------- DATE--e REVIEWEDBY - i - ------------------------------------------------------------------------- DATE__,;:�--------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------lk& Alterationsand/or recommendations:------------------------------------------------------:_:---------------------------------------------------------------------------------------------------- ----------------------1_;;,��c-------- ------ ------- ---------- ------------------------------------------------- A ---------------- ----------- ------ --- ----- -------- -------------------------------- ------------------------------------------------ --------------------------------------------------------- -------------------------------------------------------- ------------------------------------- ----------------7 -------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:--------- 3 ---------------7------------ Date----------------------------------------------- - ----------------------------- SAN JOAQUI.N,10CAL 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.