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APPLICATION FOR SANITATION PERMIT Permit No. . .... i�C�... (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued f 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-_____L � - -• - � r/1 f ------------------------------•----•------•-•-...........-- Owner's Name----------------------------� ---141-------. ------ -------------------------•------------ Phone.................................... Address------------------------------------------------- --••----- -----Contractor's Name------------------------------------ ------_----------• -- ------•------------------------------- Phone................................... Installation will serve: Residence JX Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms -, Number of baths I____ Lot size -__--��C />5 C-_ ---- - ----------------------- Water Supply: Public system 11, Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [R' New Construction: Yes,, No ❑ FHA/VA: Yes ❑ No ❑ �7_> TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well _______.Distance from foundation---/_----------Mate I --------- ---- No. of compartments__-___________ _____Size------- ---Liquid depth------- --------,_---Capacity--____xd.... - Disposal Field: Distance from nearest well------'----Distance from f ''`a`dation--------�o-----Distance to nearest lot Number of lines-----------�_______________ _.Length of each7lx__'�-#Q_'�__.Width of trench___-.. � --------- Cd Type of filter material___? --_.Depth of filter material---------l?------Total length--------l__�o_d____•_______________ � Seepage Pit: Distance to nearest well----------------------Distance from foundation-------_............Distance to nearest lot line----_----------- ElNumber 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------------•------------------ Remodelingand/or repairing (describe):---------------------------•--------------------------------------•---•----------------• •---•-------••---------...------------------------------------- -------------------------------------------------------------••----------------------------• :''"'� - ---- �.r� ------------------------------------------------------••----------•-----•---------------••----------- ---------�© =�------------- --- 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 ond regulations of the San Joaquin Local Health District. (Signed)--. -------- ------------------------(Owner and/or Contractor) By---------------------------------------------------- ---------------------------------------------------------------------------(riifle)--------- ----------------- ----------- ---------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------- -A --- -------------------------------------------------------- DATE------ REVIEWED BY--- - DATE..- BUILDING ----�---- --------- ------------ --------- --------- -------------------- BUILDING PERMIT ISSUED. --- ---- - --------—------------------------------------- DATE------------------------_---- ------------------------------ Alterations and/or recommendations---------------------- ------- ------ -------------------------------------------------------------------------------------------------------------------------- -.......................................................................................... ------- _---------------- ------------------.------------------------------------------------------------------------------------------------------------- ----------------- FINAL INSPEC 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 V59 F.P.Co.