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APPLICATION FOR SANITATION PERMIT Permit No. .1/..6 -..1... / (Complete in Duplicate) U 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 1 � f �f Owner's Name----------------------- - � __ks" ---- f------- �� - - -r r _ Phone Address •= c • ' F _T'' -------- Contractor's Name-------------• --- ---------------•-• ----------------------------------------------------------------- ----------............... Phone................................... Installation will serve: Residence 0--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other ❑ Number of living units: -------- Number of bedrooms,.__- Number of baths _ Lot size _ : .._._. _.�Ia.-�2----------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table . _:_ ft. Character of soil to a depth of 3 feet: Sand M 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 septic tank or'cesspool permitted if publiy sewer is available within 200 feet.) Septic Tank: Distance from nearest we1 pistancefr m�fQ nd No. of compartments-----..2 __-_-_Size___,_...,�e__a __� :_..Liquid depth-_____4-----------Capacity....... �_�_..��. Disposal Field: Distance from nearest well Distance from foundation Z�2:7�istance to nearest lot line_.. j Number of lines________ Length of each line----- ..............Width of trench _-�'.5'`. :........... Type of filter mate _ (_4.e-�,_ epth of filter material -/,9_._----------Total length....... .. .................... Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------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):-------------------------------------- ------•-•----•-••---•------•---•---•----------••--.....................................-•- ------------------------------------------------------------ ..........................-•••------------------------------------------------------------..............................-.............--•-------•----•---- ----------------------------------------------------------------------------------------------•-------•-------•--------•---•-------•-------•----_------••=--•--------•-•-----------•--------. ............................. ------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------................................... 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 of the San Joaquin Local Health District. l (Signed) � f,•'l -�( � i y, ,----------------------- .__.(Owner and/or Contractor) By:--•---------------'----------------------------•------------------- ---------------------------------------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i F PAR ENT USE LY APPLICATION ACCEPTED BY.......°_ -------------------------------------------- r , DATE t -� f REVIEWEDBY---------------------------------------------•---------------------------------------------------------- ------ DATE..........-.................. BUILDINGPERMIT ISSUED-------------------------------------------------------------—-------------------------------------- DATE------------------------•-----. Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------............................................................................................................................. ---------•------------------------------------------------------------ --------------------------------------------------------------------------------•----------------•----•----------------------------•-•••--- ---------------------- ----------------------------------------------------------------------------------------............. ............................... •-------................. FINAL INSPECTION BY:. -------------- ------------ Date � J 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.