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APPLICATION FOR SANITATION PERMIT Permit No*eg.:4�.`a_ .... (Complete in Duplicate) y S` -' 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. Z. JOBADDRESS AND LO TION ---- -- - --- --- -------------------------------------------------------------------------------------------------- . Owner's Name------ -------------------------------------------------------------------------------------------------- Phone..--------------•------------------ Address----------I.-- Ll'--=---- ------- 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 .l__-_ Lot size ___ _ x,_J-1- ------------------------------ Water ___________________________Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ..Y,9 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Z2,- Hardpan ❑ Previous Application Made: Yes ❑ No E�—New Construction: Yes Z�-No ❑ FHA/VA: Yes ❑ No 24--- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sep 'c Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- ' No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity--_------•----------- i os Field: 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-______--_---__-____----_-______•_____---_ Seepage Pit: Distance to nearest well--- _04_ _____Distance from fo dation-----/__1G_i__-_-.Distance to nearest lot [� Number of pits------ ____-___-_Lining material./ _.Size: Diameter___..-7-?_.--------Depth_---_.�_�__________________ Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material.__-_____-_-__-__-_-___-_._.._____._.. 4 ❑ 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an regulations of the San Joaquin Local Health District. (Signed)-------- 1------------------------ ---------------------------------------------------------------- ---(Clwaso-ondOr Contractor) ------------------------------------------ Title (Plot plan, showing size of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- ---- ------------------------------------------------------------ DATE--------------_--- - �` --------------- REVIEWEDBY------------------------------ ------- --- - ----- ------------------------------------------------------------ DATE-------------------- - � BUILDING PERMIT ISSUED----------------_------- ---------------------------- -------------------------------------- DATE---------- ----�=---------- --•----- Alteratio d/or recommendations:------- - -- -----------------------------------------------�_ -----•---------- ----------- - ----------------------- !�- - ----- ------------- -----------k - - --- -- --=----------------------.------------- ---------------------------.-------- ------------------------------------------------------------------------------------------------------ ---------------------------------------------------------- FINAL INSPECTION BY:. --- --- Date c - y -- ------------------------------------ --------- 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.