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APPLICATION FOR SANITATION PERMIT Permit [Complete in Duplicate] Date Issued 'r — ------ A - { Application is hereby made to the San Joaquin Local Health District for a per it to construct and install the work herein described. This application is made in compliance with County Ordinance 549. JOB ADDRESS AND - CATION-----_- --�� _ __ -- ---- -- -----------------------------------------------------•- ....... .------------------------- Owner's Name-------------------=----------------------------------------------- "=---------------------- Phone -----•-------------- ------ Address-------- !�i %r��---------------- - - --- ---- ...-----•---------••------••-------------- Contractor's Name---------------• A ------------------------------------------------ -------------------- Phone.. ------------------------------ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -,/--- Number of bedrooms __-;LNumber of baths J--.- Lot size r --f'J%---------------------------- Water Supply: Public system ❑ ' Community system ❑ Private ❑ Depth to Water Table 419 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe'�ardpan ❑ Previous Application Made: Yes ❑ No P��New Construction: Yes ❑ No �HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) pti Tank: Distance .from nearest well ----------------- Distance from foundation- ------------------ Material ------------------ :--------------------- .---.---. No. of compartments ---------- --------------- Size -------------------------------- Liquid depth -------------------------- Capacity--------------•-------- ispos I' ield: Distance from nearest well ------------------ Distance from foundation ------- ..--=-------- Distance to nearest lot line -----------------.r e r Number of lines----------------------------------- Length of each line ----------------------------- .Width of trench ----_.-_.._-_.----.------------ A� Type of filter material ------.-_--------------- Depth of filter material ---.-------------_-`.Total length -----.--.---.-.-----.------_---_----_----- J Seepage Pit: Distance to nearest well�A ('-Distance from fo ndation--- S�r�r--___�Dis�� to nearest lot lin ------- Number �7 0 ®� Number of pits -----/ -------------- Lining material-- R -- .Size: Diameter-- ---=1 ..---Depth--- -1---------------- Cesspool: Distance from nearest well ----------------- Distance from foundation -------------- -----lining material ------------------------------------- U ❑ Size: Diameter ----_----------------- ------------ Depth ------------------------------=- - •--------------Liquid Capacity------------ ------•gals. Privy: Distance from nearest well ----1--- --------------------------- ------------- Distance from nearest building -------..-._--.-_-._--._.---_-.--_.-. ❑ Distance to nearest lot line------- ------------ --- ------ -----------------------------------------------------------------------------------------------� Remodeling and/or repairing (describe]-------------- l" IRe=-----------------•-----------------------------------------------------------------------------------------------------------------•------------------------------------•-••-------------- ------ F-------------------- -------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ I---------------------•- I-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance.wifh San Joaquin County ordinances, State laws, d rules and r uiations of the San Joaquin Local Health District. Si ned==------------------------------- ----------{�?+ Contractor] ( 9 }By:------ ------------------------------ ------- - ------ ----------------- {Title}�f (Plot plan, showing size of lot, locatio system in relation to wells, buildings, etc., can. be placed on reverse side). s FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----- ---------------- ------- ---S-------------:---------------------••-•---=-------- DATE----------- ---• ---- REVIEWED BY --------------------------------------------- --- ------------------------------------------------------ DATE ---------- .- �" ---- . ..-... BUILDING PERMIT ISSUED ------------------------- -'--- -----(J-- ------- -------------=-------------------------------- --• DATE..------- - - - - - - - - - - - -- ----------------•------- Alterations and/or recommendations:-------------------------------------------------------------------------------.--------------------------•----------{•-. -----•------- i - -.� ---------- •------ ------------ .------------------------------------------:•--------••---......---- ------ / _ C FINAL INSPECTION BY: ----- ----------- ---- - Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strea+ 300 West Oak Street `' �� 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M , Revisea 1-57 F-P.CO.