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APPLICATION FOR SANITATION PERMIT Permit No. ___� ....._.,_...1 (Complete in Duplicate) / y S 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 compliance with County Ordinance No. 549. .JOB ADDRESS AND LOCATION. 1J -- - ��% '� {' r'`r_�; ` •,r ---------------- Owner's Name--- -4�----- ----=---------------------------------------- ----------------- ----------------- ----------------------- Phone-----------•--------------------•---- Address__-------- _,------ �----------- ------------ ---------- Contractor's Name ------------------------------------------------------------------------- --------------------------------------------- Phone-------------------------.--------- Installation will serve: Residence_E Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �a Number of living units: ----- Number of bedrooms z---- Number of baths ._/_--- Lot size --------- -------------------------------------------------- , Wafer Supply: Public'system ❑ Community system ❑ Private 5] Depth to Water Table 24�7a. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ® Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ 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__d__a--.--_Distance from foundation.--.�O-_----_--. Material---e1V'LC^ _____---_----------------- M No. of compartments-------;�---------------Size--- -_'-------Liquid depth......el-----------------Capacity-2 _------------`E-� Disposal Field: Distance from nearest well_-.__......_Distance from foundation_-- �'_--__-_Distance to nearest lot line-_------_--.- ® Number of lines---_--_J------------------------Length of each line-_--/�-a'-----_-_-._--.Width of trench_-_��/'___-_----.-------_---- - Type of filter material-/�Y- -----Depth of filter material---.4 Y------------Total length----!_A_a-_ Seepage Pit: Distance to nearest well----------------------Distance from foundation-_-_-_-__--_____-...Distance to nearest lot line----------------- Number __-_- _-,-----Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------.---------------_----_-_V Cesspool: Distance from nearest well _ ____ r_--_Distance from foundation====----------=-----Lining material-__-._--_-_-_-_--_.___-.______--.'i ❑ Size: Diameter-------------------------------- Depth----------------:- -- _ Liquid Capacity_. . ------gals.! N Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---_------------__.--._. _- ; ❑ .� Distance to nearest lot line-------------------=------------------- - -----------------------------------"-----------------•---------------------------------------- Remodeling and/or repairing (describe):----------------------`--------------------------------------------------------------•--------•---------------------------------------------•----•-••--- -------------- ----•----------•------- • ------•--------------------•---•---- -•--•--------------------------------•--------------------------------------------------------------- i -------------------------------_1----------------------------=------------------------------------------------------•------ ---------------------------------------------------------------------------- ---------------------------------------------------------------------- ----- • --- ------- 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 re ulations of the San Joaquin Local Health District. (Signed) �"li 1 �i� ----------- ------------------------------------------------------------------------------------(Owner and/or Contractors i --------------------------{Title}----------------- --------------------••----------------- ------ i. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., car' be placed on reverse side). FOR DEPARTMENT USE-ONLY \ APPLICATION ACCEPTED BY--- -- - -- --------------------------- ------------------------------- DATE_-Gz_-�! �J"7----•--------------------- - -- --- - REVIEWED BY-------------------------------------------------------------------------------------------------------------------------- --- DATE=----------•-----------•------------- --------------------- BUILDINGPERMIT ISSUED-------------------------------------- ----------------i---------------------------------------------- DATE---------------------------- ------------------------------- Alterationsand/or recommendations:----------------------------------------- ---------------------------------------------------------------------------------------------------------- ----------------------- --------- ------------------------------------ �: � -- ------------`-----------------------------------------------------------------.---.------------------------------------------------------ ------------------------------------------------------------------------- FINALINSPECTION BY:_------------------------------------------------------------- --- Date------------------------------------------ ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West flak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M , Revised 1.57 FY.CO.