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APPLICATION FOR SANITATION PERMIT Permit _o:. Q--...... (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 ijn compliance with County Ordinance No. 549. `.Sso• � 0 7- oQo-Sg -_-- J --- - _ ►--_--�- - o._____________ ---------------••---••---------- ----- ' s+J - ----------------------------------JOB ADDRESSAND CATI N Owner's Name--- ---------s -------------------- Address Phone----------- •----------------------- ----------------- - -- -- Address--------- Contractor's ------ Name - ------ - --------------- - - ------------------------•-------- Phone------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size _ __. ._ --------------------•--------------- Water Supply: Public system ❑ Community system ❑ Private, Depth to Water Table-s%__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loa m& Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes [❑ No�M New Construction: Yes [r No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest well 1,S"G-'E'__Distance from foundation__Iq-____.__--Material________________________._.___-. _ of compartments= , ------�--Size --------------------- ---- -- .# ] - ,r Liquid`depth -_---------------Capacity----- ------ -- - Disposal Fiefd: Distance from nearest well. o"Q-_____.Distance from foundation_1_Q-----------Distance to nearesj lot line---------- Number of lines_______ - 1 _ ,r� L ngth of each line____gl}______ ------- of trench__ ____ __ _ __------- Type of filter material __ flf- epth of filter material__-- --------Total length___ __ _----� p Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line,------- ❑ N'umber of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-------r--------Distance from foundation--------------------Lining material------------------------ -_ .__.____ 1, ❑ Size: Diameter------------------------------ -------Depth------------------------------ ---------------- ----Li uid Ca acit q p Y ---------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________._____________._, ,.❑ . Distance to nearest lot line-- ----------------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)--------- ------ -............. - ------- -- t�� -------------•-----------------------------------••------------- -----------•----------•----•-----------------•----------------------------------------------------------•----- -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, Sta a laws, and rules a��egulations of the San Joa in Local Health District. ' + i (Signed)_._ •------- --• ------------------- ..... - --------------------------------------(Owner and/or Contractor) By:----- r a-------- - -------(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 APPLICATION ACCEPTED BY_4444' _________________ DATE�_@`3'_ ' - =-------------------------------------------------- ----- -REVIEWED ------------------------- BY--------------------------------------------- ------------------------------------------------------------------------------ DATE BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------------------------. DATE------------------------------------------------------------ Alterations and/or recommendations:------------------ ---------------------------- ------------------------------------------------------------ ------ - _ -- -------- r "" -- '----- ----'-----• *--------------------- ----'-•- '`-°- ..---- "'----• - r ; - __ --- ---------------------------------------------------/-------------------------------------------------------------------�-------------------- --- '-- ----------- --' =---1411'"7 �" -,�-f------------•------------- FINAL INSPECTION 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 FY.CO.