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ell APPLICATION FOR SANITATION PERMIT Permit No.0 (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 0 Ir Owner's Name-- ------ Phone------------------------------------ Address---------- .! e------ . Contractor's Name--------- �'ld ' Phone Installation will serve: Residence E!�`Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms --ot- Number of baths ./____ Lot size A_. ----- ---f Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table 0,0_ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,Hardpan ❑ Previous Application Made: Yes ❑ No P`� New Construction: Yes ❑ No 2"FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) .Isepti ank: Distance from nearest well_________________Distance from - foundation--------------------Material_______-_-________-_-_ _-__--_-.•____--.___-_---_ No. of compartments Size................................Liquid depth--------------------------Capacity----------------- Dspo aId: 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--------------.__------Total length---------------------------------- Seepage __--_---_______--__-_________-__- See a e Pit: Distance to nearest well___ _ ---bistance om ndation__ p g G�j►',ic_ _ J-4---##-.-.Di tan�� to nearest lot line, �.. [L}/� Number of pits----/---------------Lining material- ---Size: Diameter-- V---------- �, ------- h - 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 f the San Joaquin Local Health District. 16� C JI (Signed)--------- ....----- n4 �------ �- (Qriwri#or Contractor) By:-------------.............................. ---------- `- ------------(Title)--------1� � -------------------- (Plot plan, showing size of lot, loc n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------- -------------- --•--•-- --------------•---------------- DATE-------------------------------------------------- REVIEWED -------r REVIEWEDBY---------------------------------------------- ---------- ------ ----------- ---------------------------- DATE...................................... -- ------------ ------------•------------------------------------------------------------ -- ----- BUILDING PERMIT ISSUED-_-------_----------- _________________ DATE-------------------------------- / -------------- Alterations and/or recommendations________________________ ___. _ .. _____..___._______. ------------- -------------------------------------------- ---------------- ----- ----------- ------------------------------------------------------------ --/--- --------------------------- ...........................----•-----•-------•-----•----- --• --------•------------------------------- -------- -------------------- ---------- --- ------- ------- ------- -- ------------ -O&J------------------------------------------------ ----------------------------------------- ----- ----- -------- ft* FINAL INSPECTION BY: _ ._. _ _ l=1__ _-- Date----- / ------------------------------r �� --•------•-•------------------ 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.