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,1 T APPLICATION FOR SANITATION PERMIT Permit No. ..... (Complete in Duplicate) S! Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with Count•Ordina e No 54 m ----------------------------------- ------------------- ----------------------------- JOB ADDRESS AN OCATION ' �` ' Phone-------------------------------•- - ------ -------------------------------- Owners Name........ ------- ---------------------------------------------•------------------------------- --•---Address Contractor's Name--- ----- ----- ---- --- - "----- -------- - ---- ---------•------------ ---•-_-- Phone................................... Installation will serve: Residence partment H ❑ Commerc ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __t--__ Number of bedrooms __umber of baths __t--- Lot size f- ..dtoC��------------------------------------- Water Supply: Public system Vommunity system ❑ Private ❑ Depth to Water Table . ft. Character of soil to a depth of 3 feet: and ❑ Gravel ❑ Sandy loam ❑ Clay L m ❑ Clay ❑ Adobe e - irdpan ❑ Previous Application Made: Yes No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No LJ' 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--------------------Material ____________________________-___ No. of compartments--------------------------Size---------------- -------------Liquid depth------------------------ Capacity---- -------------- Di o a Field: Distance from near t well_ _ istance from foundation__1�_______-Distance to nearest to *e_ s---_. Number of lines____________ _ _______ Length of each line_.__ Width of tren gra Type of filter material �,�l'� epth of filter material------f. ------Total length.-- •---------------------- Seepage Pit: Distance to nearest well __________________Distance from foundation....................Distance to nearest lot line................. ` ❑ Number of pits----------------------Lining material__-__________________Size: Diameter-------------------_.__.Depth-----------------__.................. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------------- El 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 ---------------------- - - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County or ' antes, State laws, a rules anc.,re lations of the Sark Joaquin Local Health District. - ASSigned) - -=- - - -------------------•- --- ----- ---- -------- ----------------- --------------- -- --.._-------------(Owner and/or Contractor). By: x_. -----(Title)---------------------------------- - y. .._ ._.. .-- - --- - ------------------------------- - - -- -- ---------------- (Plot plan, sho i— sized of, location of system ' reTaflorrto wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------- ----- ---------------------------------------- DATE---------- ----- ----------- REVIEWED BY--------------------------------------------- -- ----- - -------------------------------------------------------------- ----------- ------------------ ----------------- DATE--------- ••-•---- BUILDING PERMIT ISSUED-----------_--------- - --- - ------------------------------------------ --------- DATE- - Alterations and/or recommendations:--------- ---- -------------------------------------------------------- . •--------•--•------------------ -----------------------------------------------------•------------------------------------------------•---------------------------------------------------------------------------------------------------------------------- •---------•-----•---------•----------------------------------------•------------------------------------------------------ --------------------------------------------------------------------------------------------- -- ------ ------ --------------------------------------- -----•------- Ile INSPECTION BY:. f ----- --------- Date----------- :Z ----------- -------------------------------- FINAL 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.