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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 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---�01 �------ ---- -------------------------•--- ---------------- ------- --------....................... Owner's Name..... -------------------------- -------------------------------------- Phone_. Address--------*^C "-- r Contractor's Name---- ----------•--- Phone............ - -------•-_-•---- Installation will serve: Residence gpo"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El e --! - ............................. Number of living units: _/_._ Number of bedrooms __`___ Number of baths __�__ Lot size _-��--�_ >�0 Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _7� i ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe er-Pardpan ❑" Previous Application Made: Yes ❑ No �New Construction: Yes ❑ No [!�- FHA/VA: Yes [2 ' 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-----------------Distance from foundation--------------------Material__-___-__:-_____-__.__._-___--_:------.•_____-_-. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-------------------•--• Disposal Field: Distance from nearest well --.___.-------.-Distance from foundation____________________Distance to nearest lot line..........._.___. ❑ Number of lines-.---------------------------------Length of each line------------------------------Width of french:____-_.-____.___---____......... Type of filter material-------------------------Depth of filter material----------------------- length________________________________________ Seepage Pit: Distance to nearest well------ - _ _--.___Distance from fou ation _________________Dist nce tg nearest lot I Y' Number of pits----/ --------- ---Lining material Size- Diameter.jk&' Depth--- ------ 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 ___-.-_.__-______________.Distance to nearest lot line. - Remodelin and or repairing __________ ------X�,�... , ------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- 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 reg ati*ofSan Joaquin Local Health District. Si ned /5.( �9 ) �'� Y( �---By:----••••----•--- -----------------------------(Title) --- (Plot plan, showing size of lot, locat' of systn to wells, buildings, etc., can be placed on revers ide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_--------- ---------------1_ - -_.-_ DATE - - -------------------------------------- - REVIEWED BY ---••• DATE -------- YJ------ - •-------- --------- --- -------- --- -- ----- BUILDING PERMIT ISSUED -------------------------••_------------------------------ ------ DATE------------------------------- ............................ terations and/or r co mend ons:-_________ _________ ` f`Q;fJ.5. t m -- Pr" - 4� r ._ �.. ._ ..................... __________________________________ ----- ------ -- _ -_._ - ............ _-_. ___ ._.__. _. -_ FINAL INSPECTION BY ----- •--- �. `....................... Date---I-- k - - --------------------------------- --------- 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 Revisea 1.57 F.P.CO.