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lPermit No. __ .��-- - •• APPLICATION FOR SANITATION PERMIT ri (Complete in Duplicate) Date Issued ---- an Joaquin Local Health District for a permit to co struct arld insWI the w rk herein described Application is hereby made to the S . This application is made in compliance with County Ordinance No. 549. k� 0 �� ------ --- ---- Z-------------------------- - ----------------- 1------------------------- JOB ADDRESS AND --- Phone- Owner's Name_ lJ--�--- -------- Address-_ -------- -----•-----•-----•- •------------ ---- - -- ------,t •----------------•----- Contractor's Nam Phone-------------------------•--------- - - - --------------------- - Installation will serve: Residence Apartment House ❑ Commercial [I Trailer Court ❑ Motel]Other ❑ "Number of living units: '_------ Number of bedrooms -'_-_.- Number of baths --- Lot size -/ Water Supply: Public system pr Commuriity system, ❑ Private ❑ Depth to Water Table 0-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam, Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan 0 Previous Application Made: Yes ❑ No fJ New Construction: Yes 5Q No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-�_ttl�__Distance from fo�u/ndation- t 0- ------.�M/aterial_.._--------------_ No. of compartments------;-- ---------------Siz tll _ e` �"_!®_ ��quid depth---I-yy---------------Capacity- --i--- --- I Disposal Field: Distance from nearest well/ _Distance from foundation t --_--.Distance to nearest lot linW& 1 Number of lines----. ------- ------------ Length of each line----------Y_j7------------Width of trench__ -. '�__-.------------------ ' si Type of filter material lr-__- Depth of filter material-_-Ll--r--------Total length Pit: Distance to nearest well----------------------D•sstance from foundation....................Distance to nearest lot line__-_----___._-.-. ❑ Number of pits---------------'------Lining material----_-----------_- ---Sizes:.,;Diameter----•-----__---- D ------ epth------ ---------- dation_l___-.--__-.--__--.Lining material_--_---_-__-----___--_----------_-• �: Cesspool: Distance from nearest well-----------------Distance from foun ❑ --------Depth-------------------------- -Liquid Capacity------ -------------gallp Size: Diameter--------- ------------ - - - - - ----- -- Privy: Distance from nearest well ------------ from nearest building ----------------------- Distance to nearest lot line------------------------------------ ---------•------------------•--•------------------- ------- Remodeling and/or repairing {describe):----______--------__-_ ----------------- ------------------ -----------------•------•---•-------------- ------------f -=----------------------- --------------------------------------------------------------------------•---------------------------- ----------------------- ---------------------------------=-------------•--------------------------- --------------•------------•--------•-------------------------•----------••----- ---------•--------------------------------------------------------------------------------------------------------------------------- I hereby c6rtify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and ru es d r �'ulations of the San Joaquin Local Health District. (Sign_ -r --------- --------------------------------------------- --------------------------------------(Owner and/or Contractor) - -- ----- --------------------------(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 p APPLICATION ACCEPTED BY-. _ ;�°� ----------------------------- DATE--�17------------------------------- DATE------------------------------------ - ----- -------------------- ----------------- DATE--------------------------- ------------ --------------- REVIEWED BY------------------------------------------------------------------------=------------------------------- - BUILDING PERMIT ISSUED--------------------------------------------------------------------------------- -- Alterations and/or recommendations:----------------------------------------------------------------------------------------------------------------- •---- ---- ------------------------- FINAL INSPECTION XC-' �?�/ s --:---�'7�} � ------- -� 1.� 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 1.57 F.P.CO.