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1�II�1 \0 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 7�j R 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 Ordina ce No. 5 JOB ADDRESS AND LOCATION.._.- ........... - - Owner's Name ` ' =------•----•-------------------------------------------•------------------ Phone----- •---•---- Address ` �`�'. ••-- •---------------- -- ------------------ --- Contractor's Name-------------- "---------------------------------------------------------.................... Phone................................... --------------- Installation will serve: Residence `Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: __/__ Number of bedrooms __/__ Number of baths .___-_- Lot size Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 3% ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe&-**Pardpan ❑ Previous Application Made: Yes ❑ No F�` New Construction: Yes ❑ No &' FHA/VA: Yes ❑ No R4— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) tic. k: Distance from nearest well-_.-____--_--__-Distance from foundation....................Material No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity.-•-------------------- spos ield: 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-------------------------Depth of filter material--------------- Total length.__-____-_-____-___--_____---------_.---_- , PPit: Distance to nearest well �z*�'��-:_Distance from ou ation_KQ------......D'stance to nearest to line�w_..... Vpits \ Number of pits-----/-------- - --Lining material-/,__l ize: Diameter Depth o'�' sspool: Distance from nearest well___-_-_-___-----Distance from foundation___________________Lining material--------------------------- ie _.... _.� ❑ Size: Diameter_--------------------------- -------Depth----------------------------------------------------Liquid Capacity.-.-----------------------.gals. v Privy: Distance from nearest well---.:--------------------------------------------Distance from nearest building------------------------------------------ F-1 --____ :.----__-._--_-__-___-_--__--_.❑ 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 Loc Health District. (Signed) �� ems'' 'j1' - ---- - ----------------- Contractor) By:...................-------------------- --- -------------- -----------------------------------------------------(Title) �si -�-------------- (Plot plan, showing size of lot, ation of system in relation to wells, buildings, etc., can be placed on re FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ---------------------------------------------------------------- DATE-------- ---............................................... REVIEWEDBY-------------------------------------------------- --------- ---------------------------------------------------------- DATE----- �---------------------- ---•--_-------- BUILDING PERMIT ISSUED......................... =--- --------••----.................................................. DATE--------- - --------e------------ Alterations and/or recommen j ions-------------- -- --- -- ----------------------------------------------- -------------- ------------------ ---•---4----•- ------------------------ ------------------- - ------ # ------ ---•••• - . . .. ----- ---------------- . --- • ----••- - ---------------- ----- ---•-• ---------------------- - - -- 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.