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APPLICATION FOR SANITATION PERMIT Permit No. .__� '1..�_rf.. (Complete in Duplicate) z v 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....... _ '� _.'' --. Owners Name---------_ =C=----------- -- ------------------ -------------------------------------------------------- Phone------------------------------------ - 0 '� -'ci Address---------- --•-------- ---- ------ - Contractor's Name-- ------------ ------... ---------------- _ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --�-__ Number of bedrooms 2--Number of baths '.3___ Lot size ----- ____________________ Water Supply: Public system 04/ Community system ❑ Private ❑ Depth to Water Table 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 sese�pVc tank or`cesspool permitted if public sewer is available within 200 feet.) peptic Tvnt ) Distance from nearest well_______________Distance from foundation--------------------Material------------------------------------------------- No. -__-..______-___--_ .-_-_-_----_.__4-_ ____._.. No. of compartmentsLiquid depth___._--_______.__--.____Ca acitY-------------------�- J �_.___._...�is osDistance from nearest weIJDistance from foundation___Y-0--------- to nearest lot lin` C a ` T Number of lines-__-____�___._�___.__. .___Length of each line_____c�_!1_._.-�t____.Width of trench__.-- .�/____._.__________ (' k Type of filter material.____�__2�_`�___Depth of filter material-_.--J)---------------Total length-------.3'e_____--------------- Seep ______________` Seepa�9e Pit: Distance to nearest well_'_ '_ �✓C_.Distance fr m foundation___- 7_.........D stance to nearest lot line._- ---_.-_-_. ® Number of pits-_--(____-_---__--.Lining materialfB_ . _Size: Diameter_____3-'--------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 to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe�:_.r fr�--G c. t=' _____________ __�__.--- _— ------------------------- - ---- ----- Ur------------ - --- :7- - ---'- ____ ___________________________________________________________________________________________.__________________.___--____-_-__________-____-_-_________.____________ ____---_ __ _-_ 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 rule and regulatio/n /fie San Joaquin Local Health Disfirict (Signed)------------------------- � =1 n and/or Contractor) ��?•` �" ------------------------------------------------------*'�-�r--i �� "r '. Title ------ i ---- (Plot plan, showing size of lot, location of sys+em in relation to wells, buildir , etc., can be placed on reverse side). F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- f ----------------- --------------------- ------ DATE--------- ---------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------ ------------------------------=---------------- DATE------- ------------------------------- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------- -------------------------------------------- ----------------------------------------------------------------------------------------- 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 F-P.CO.