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APPLICATION FOR SANITATION PERMIT Permit No. n (Complete in Duplicate) s QDate Issued ----- p 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 Ordi e No. 549. JOB ADDRESS AND LOCATION------� C'l _ -- A.. ---------------------------------------------------------•-•---------------- _ Owner's Name %91 ------------------------------------------------------------------------------------------ Phone------------------------------------ Address--------- --------- _ - ----------------------------------------------------------------------------------------------------------- -- Contractor's Name -• Phone--------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ y Number of living units: I--- Number of bedrooms _ _ Number of baths ___e__ Lot size ____,>{_ ,QQ_____________________ Water Supply: Public system ❑ Community system ❑ Private 93--6epth to Water Table eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes 4o M----New Construction: Yes Ln- No ❑ FHA/VA:Yes [a- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic T�j Distance from nearest well________________Distance from foundation____________________Material-_____________________________________-________. X /� f No. of compartments------------------------Size-------------------------------Liquid depth------------------------Capacity----------- ------ Disgosal Field: Distance from nearest well____________ __Distance from foundation:__._.____________-Distance to nearest lot line_________________ rX411'iW�r Number of lines-----------------------------------Length of each line________________-____._______-Width of trench____-_________________-__________ (� Type of filter material---------------_---------Depth of filter material--------------------_-Total length---------------•-------------------_______ `�}4 Seepage Pit: Distance to nearest well-_e _-__.......Distance fr foun ation__1�_____,__..Di to/c to nearest lot line__________dr 'L Number of pits______________Lining material---�_Cr_�Size: Diameter.___ _ Depth___ZQ__ _______________ (� Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material______________-__________-_-_________ a Size: Diameter-------------------------------------Depth------------------------------ ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building--------------------------______________- ❑ Distance to nearest lot line----------------------------------------------- -----------------�---------------------------------------- -- ---------------------------- Remodeling and/or repairing (describe):________ ____ _-______ � '/__;� .- ________________________ -------------w•--- --------- -F -------------------------------•----------------------•---------------------------- -------------•--------------------------------------------•----•=-----------•_.----------------------------------------------- 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 regulations•o a San Joaquin Local Health District. (Signed) X " =` = I�r Contractor) By:--- ----------(Title)-• - (Plot plan, showing size of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY--------- ------ --- ------ ----_--------------------- DATE---------- REVIEWED BY------------------------ --- ---- - - - ------- DATE------ BUILDING PERMIT ISSUED________________ ____.___ DATE_________ _A___ ------------------------------- A __________________._..__.____ Alter tions and/or recommendations------------------- --------------------------- --------- ------------------•----------------------------___------- _ --- -------------- r._. �. C �� - -- ----- ------ -- - --- ----c----------- t ••.j� / ------•--------------•-- { ----------•--�-----------•------------------------- ---•----/:A�,/ ------•---•----• – ---- -•-------- 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.