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APPLICATION FOR SANITATION PERMIT Permit No. / ! 1,./ (Complete in Duplicate) 7� ( /4y-rf 1,/ 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 L C TION.�t o / C ..........................................------- Owner's Nam _ -- ----- -:T�--••------_— ---_ _ Phone Address --•••-• _----•- ....._----- r V ---------------------------------------- -----------------------------------•------ ---..._.- Contractor's Name---- 1 Phone Installation will serve: Residenc ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _._ Number of bedrooms __y Number of baths ______. Lot size __._ __ Water Supply: Public system [ r' Community system ❑ Private ❑ Depth to Water Table 0 ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ [' Adobe Hardpan171 Previous Application Made: Yes ❑ No New Construction: Yes E] No ❑ FHA/VA: Yes E] No (, -` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sep Tank:�- Distance from nearest well_________________Distance from foundation ___...._....__.Material--------------................................... .�-06!<'`_� No. of compartments--------•--- -----------Size---•------•---•------ - --.._Liquid depth---------- ---- ------Capacity •--•-- - ------- Di osal F Distance from nearest well-----------------Distance from foundation __________-Distance to nearest lot line._--_. ^' Number of lines__________________________ ______Length of each line...-------------_.............Width of trench _.______•__- Type of filter material---------------------pDepth of filter material___________ _!---Total length..................._._._..__.._.. Seeps it: Distance to nearest well ._�:�%�""�___Distanc ro foundation. �_�.-____.Distance to nearest lot Size: Diameter___•. _. Number of pits------!_-------------Linmg material __ -._-------Depth_ • ---------------- ----------- Cesspool: ___..__ - K� 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):-----------------------•-----•------------•------- ---------------------------------••----•------- •-------- J -------------------- -----------------------------------•----------------------------------------•----------•--•--•-------•-•--------•-----------•----•-----•-------------•--------•-•------•--------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat aws, and ules and regulat'ons of th San Joaquin Local Health District. (Signed)----- .. L -Y ! '------- -------- - - {br Contractor) --- r By:. ------------------------------------ ' -`� `�?f (Title) ,fit'------ ----------- --- - -------- (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------------------------- ------------------------------------------- DATE---------------- •+-----------•---------------•--- REVIEWEDBY------------------------------------------------ -------- I---------- -------------------------------- DATE......... BUILDING PERMIT ISSUED------_-------------------- ;--- •-----------•--------------------------------•---------- DATE I--------------•- ••--------- ------ Alterations and/or recommendations:------------•• --------------------------------................................................ ........................ -------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------•-------•-------------------------------------- FINAL INSPECTION BY:._Cj)// .--- Date..... _.__1--- =..- __ ,_ 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 Ll ES-9-2M . Revised 1.57 F,P.CO.