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I ° APPLICATION FOR SANITATION PERMIT Permit No. __L_`S ...... (Complete in Duplicate) oma/ 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. a JOB ADDRESS AND LOCATION_ ---- =--- Owner's Name --- ---- - ' ------- --------------------------------------------------------------- ----------------- ------ Phone------------------------------_-- Address 1 - --------- _-__________________________________________•----------__-----_--__-. ------ - ---------------- ------------------ -------------------------- ------ Contractor's Name--------- -- ---- - ------------------------------ Phone................................... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -!1- Number of bedrooms Y_ Number of baths _l_ Lot size -----1 -------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe �iardpan ❑ Previous Application Made: Yes ❑ No 021e-New Construction: Yes ❑ No FHA/VA: Yes ❑ No [4-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) epti A. Distance from nearest well_________________Distance from foundation--------------------Material_:_____________________-______.___-____-_-_-____. No. of compartments---------- ------ Size--------------------------------Liquid de th___.___-___________ Capacity Dispo Field: 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---------------------------•._............ t Seepage Pit: Distance to nearest well_-____"_______Distance frpm fou ation_ ..__..Distance to nearest lot line----------------- [Zr'� Number of pits _ Lining matenal ,y01Size: Diameter —--- p De th o'�''S' 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-------------------------- ---------------•------------------------------------------------------------------------------------- iv ` w -V Remodeling and/or repairing (describe): --OR-R-- ---fe----- ! ---------------------------------------------------•------------------ ----------------------------------------------•------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- 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, d rules and regu tions of he San Joaquin cal Health District. (Signed) - ---- - - - --------- - - --------------------•-- + 'lie+' Contractor) By:...................... . -• --•-- -----------1. --------------------------------------------(Title) = ''`---------- (Plot plan,.showing size of lot, I ion of system in relation to wells, buildings, etc., can be placed on rever side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- -- - -- -- ---------------------------------------------------------------- DATE---- ----------------- / REVIEWED BY ----------------------------------------- --- -- - - -- - -------- ------ ---- -- -------------------------------- DATE----------------- =/ - =---------------------_.-_._ BUILDING PERMIT ISSUED................ - --- - ----------------------------------------------------------------- DATE------------ Alterations and/or recommendations-- --------------------------------- ----------------------•-------------------------------- __ - ---------------------------------- ----------------------------------------------- -------------------- ------------------------------ --------- -- ------------- --------------------------------- -----------------------------------------•----- - -- -------------------------------- - ---------------------•----- ------------------------------------------------- - ------ ------------ - ----------- FINAL INSPECTION BY-0 Date-__--__ ____ SAN JOAQUIN LOCA 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.