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APPLICATION FOR SANITATION PERMIT Permit NQ. (Complete in Duplicate) < - .Date Issued / 17 CL3`0- n Application is hereby made to the San Joaquin Lpcal Health District for a permit to construct and install the work�e This application.,is made.iril compliance with County Ordinance No. 549. �� lam-- ''ff JOB ADDRESS AND L CATION__ ---- - --- ,�yS. J Owner's Name X� --- ---- Phone-------------------- ------- b - l Address------------- I . :��_ �' - = ----------------------------------------------------- Contractor's Name----------- Phone Installation will serve: Residence ❑ ' Apartment House ❑ Commercial RT 'Trailer Court ❑ Motel ❑ Other ❑ Number of living units: "'±___ Number of bedrooms ___- Number of baths _ -__ Lot size __ _ _________________________ Water Supply: Public system E] Community system El Private �epth to Water Table /if ft. Character of soil to a dep#h of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe [] Hardpan ❑ Previous Application Made: Yes ❑ No n7New Construction: Yes g?"No ❑ FHA/VA: Yes ❑ No [P— TYPE.OF INSTALLATION��AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 1M `. Septic Tank: Distance fromxnearest well_r ______.Distance fr m found*pion----- -------Materjal---- ,_ - No. of,compartments_____,°�______________Size___ __ Q_:___Li Liquid de th-______ . Capacity q p '� p e from nearest welf_�._a�------Distance from foundation___�e____ Distance to nearest lot-line----- Number of lines-------- -. _---- A �: r__/__ &engfh of each line__--__ __ __� __-_-_____._.Width of trench_______ _____ie� If i j�is osa re istancType of filter material-______._ p_ _ e Depth of filfier matenal__ ____._.__._Total length_ i! _�.--_------------------ Seepage Pit: Distance to nearest well______________________Distance from foundation___.__.--___.___._..Distance to nearest lot line_______-___._____ ❑ Number of pits---------------------Lining material------------ --------.Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance, from nearest well-----------------Distance from foundation--------------------_Lining material__..____.-_.-___.__________-_________ ❑ __ –Size_ Diameter=_---=-----------------:---- --------Depth_ ------------------------------------------------ _ Liquid Capacity-------:----------------- -gals. r�1i Privy: _ Distance from nearest well-------------------------------------- -_-__.._._Distance from nearest building __ _________ _ __________ -_--- ❑ Distant to nearest lot line------------------ ------------ - -------------------- Remodeling and/or repairing (describe):______--_ •:: �M. ---- ------ --.f, --------- `------------ l _- ----- --------- --' ---------- ----------- ------------------------------hereby certify that ---- ------ --------------------------------------- - -----------------------------------{ ----------------------- -------------------------------- phave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and,rule and regulation . of the San Joaquin Local ealth District. (Signed) By:---------------- -� r (Ti#le) Contractor) l` (Plot plan, showing size of lo}, locatio system in relation to wells, buildings, etc., can be placed on reverse side). l I FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED'I BY__SZ--------- - --- -- ---- ----- - -- DATE-$ ------------------------ --------------------------- --- - ------- ---- -- ----- -- - -------- - --- ------ - REVIEWED BY------- ------ Y ------ ---------------- -------------------------------------------------------------------------------- DATE----;-4- L .. ---------------------------------------------------------------------------------------------------- DATE----- Alterations and/orBUILDING Trecommp - ndafions-------------------------------------------------------------------------------------- ------------ -- -------------------------------------------------------•------------------------•--------------------------------------------------------- ------------ ------------'---------I-•-------------------- ------•--•---------------------•----•-------------------------------------------------- ----•--------•------------------------------------- -----------------•---------------II-----------•-------- ----------------------------------------- -------------------------- ----------- -- ----- - ------- ---------- ---------------------------------------------------------------- ----------------- I - FINAL INSPECTION BY:---------------- ------- -------- ------ ------ Date--------------u -- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT " 130 South American Street 30D West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2p�� • Revisea 1.571 F.P,CO. r t6 I