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( (Complete in Duplicate)APPLICATION FOR SANITATION PERMIT:, Permit No. } All"\ 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 County Ordin ce No. 549. JOB ADDRESS AND LOCATION T Owner's Namec ------------------------------------------------------------------------------------- Phone--------........................... Owner's ------------- ----------------------------------------------............................................ Name ---------•••-. - '-' ---_'._ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _Z__ Number of bedrooms 1!t_ Number of baths __,/_. Lot size __ _ _ o _B___________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _f_Q_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No [!'^ New Construction: Yes ❑ No [�4— FHA/VA: Yes ❑ No �---- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septi lank: Distance from nearest well-__--_-"--_______Distance.from foundation_______________"___.Material______"____--___.."__-. ._----___."_-____-_-. .0 No. of compartments----- _____-_"____-_Size--------------------------_,__-Liquid de th__-_______-_-----_______Capacity Disp sal ield: Distance from nearest well_---.----------Distance from foundation--------------------Distance to nearest lot line................. Number of lines-----------------------------------Length of each line_______-____-____-___--__"-.Width of trench"__-_____-_"_____-..-__.----._--___ f Type of filter material-------------------------Depth of filter material-----------------------Total length,------------_._--.-..._---__._________. Seepage Pit: Distance to nearest/well. ? '_ Distance r m o tion.___....�..__..Di a �e to nearest lo-Llinj._ _____-__ Number of pits_____,/ ___ -------Lining material__ ize: Diameter____-. ----------Depth------ ✓_._11-__-_-______ Cesspool: Distance from nearest well-----_-----------Distan a from fo dation.-------------------Lining material_______-____._-------_-_-"____-_-__-_. ❑ 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 I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulati s of the San Joaquin Local Health District. (Si ned 9 )--------------------- -- ------- ----- - --- ----------------------- --- •--- -----------------(Qt10an11 air Contractor) By:------------------------------------------------------------- (Title) '� .. "� - ------------------------------- - (Plot plan, showing size of lot, location of sy a in re.ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. .... _.----- --- ------- ------------- ------------------------------------------- _ _ DATE_'.. _____________•__._-_-_____-___..____._____________ - REVIEWEDBY-------_------------------- --- --------------------------------------------------------------------------------------- DATE- �-�-.� ---------------------------------------------- BUILDINGPERMIT ISSUED-_------------------------------------------------------------------------------------------------- DATE"--"--CA----------------------------------------- Alterations and/or recommendations------------------------------------------------------------------------------------ --------------------------------------------------------------------------- ----------------- _ - --- ------ -- -- -• -- -- ----- ------------------------- --------------- -- ------ -4tz , -------- ------------------------------- ------------- FINAL INSPECTION BY:-------941t,- --- 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 FY-CO.