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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 co plianrnpwith Cou ty Ordinance No. 549. JOBADDRESS AND LOCATIO - ---- ---------- -- --------- j `�° = ----------------I---------------------------------------------------------------- Owner's Name----/ `----- - -------------------------------------- ------- ---- ----------------------------------------------------------------- Phone------------------------------------ Address--------- ±:_ " --------------------------------------------------------•----------------------------------------------------------- Contractor's Name ° -------------------------------------------------------------------------------------------------------------------------- Phone----•----------------------------- Installation will serve: Residence 1;� Apartment House ❑ Commercial a Trailer Court ❑ Motel ❑ Other ❑ A Number of living units: -------- Number of bedrooms ________ Number of baths -------- Lot size ------------------------------------------------------------ Wafer Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft- Chairacter of soil to a depth of 3 feet: Sand-[] Gravel ❑ Sandy Loam [❑ Clay Loam p Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septiq,tank or'cesspool permitted if public sewer is available within=feet.) Septic Ta ti + Distance from nearest well_________________Distance from foundation-------------------Material------------------------------------------------- Ely.,No. of=compartmknts-#-----------------------Size------------------------ .......Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well---�-�_----Distance from foundation-----Q_._______.Distance to nearest 10 line___ --------- Number of lines--- ---------)---------------------Length of each line_....4_`,_�---------------Width of trench__4 �-_.--_---_ -------------- 4, � oP Type offilter material__ __._ kmk-Depth of filter material___.1$"___-________Total length__' 7-___________•_____________________ 1 Seepag it: Distant�o.nearest well_.__-9"�_______Distance frffom f undation__'3-_a_-________..Distance to nearest lot line--_ - [� Number of` rts_ -- _-- ----Linin material 4Vl_ ____.Size: Diameter_._'�'��'__--__..____.De th_____-- p� g p Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___.___._____________________-___. ❑ Size: Diameter-------------------------------- Depth----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well--------------_----------------------------------Distance from nearest building___.________-______-_-______..______._. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------� Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------; ------------------------------------------------------------ •------------------=----------------------------•-------•--------•----•----------------------------------------------------------------------------------------- ------------------------------------- --------------••--------------------------------------------------••----------------------------•--------------------------------------------------------------------------------------- I hereby ceI tify that I have prepared this application and fhat the work will be done in accordance with San Joaquin County ordinanc St a laws, and rules re tions of the San Joaquin.Local Health District. 7 (Signed)----- --------------------- ---- ----- -- --------------- -- ---------------------------------------------------------- -------------------(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 ONLY19 �--p APPLICATION ACCEPTED BY-- ----------------------------------------•----------------------• DATE10—J' `' ,r-------------------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------ ----------------------------------------------- BUILDINGPERMIT ISSUED--• --------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------- ---------------------------------------------------------•-------•------------------•------------------------------------ ------------------------------------------------------ ------•----------------------------- -------------------------------------------------------------------- --------_-----------------.---•-•--------------- -----------------------•--------------------------------------------------------------------------------------I--------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.. Date_..l® Z�� 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.