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APPLICATION FOR SANITATION PERMIT Permit No, 7U.)..... (Complete in Duplicate) W Date IssuedS 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------ .."'' e4 !` �!/ C'`�• Owner's Name-------------------------f—= •-- ------------------------------------------------------ Phone�i4_ Address........................................................= --------------------------------------- ----------------... Contractor's Name-------------------------------------------- --------------------------------------------------------------------------- Phone........- -- Installation will serve: ResidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other� 1. Number of living units: -------- Number of bedrooms I... Number of baths .1----- Lot size ...... `.........:...._ Water Supply: Public system ❑ 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 ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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....!�Q....Distance from foundation-------- Material---- No. of compartments.--__-:___�--------Size... ...Liquid depth_..______ --_-____-Capacity...... Disposal Field: Distance from nearest well _ ...Distance from foundation..___.] ..Distance to nearest lot line _ 1!� Number of lines __-__.- __.. -___Length of each line--------------e Width of trench .50(7 Type of filter material—_____Depth of filter material____-_____/< __-___Total length..... . ....... ...2_4 Type 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 ------------------- - F-1Size: Diameter-- -------- --- --.Depth----•---------------------- ---------------------Liquid ,Capacity .....gals., Privy: Distance from nearest well .. ___-__________ -_ _____ --_Distance from nearest building . ❑ Distance to nearest lot line---- --------------------------------------------------------I----- Remodel' g 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�anddgulations of the San Joaq in Lacal Health District. (Signed)-f'-•--- .0-_ --- -- -------------------- ---------------------------------_-(Owner and/or Contractor) By:..................................-------------------------------------------------------- -----(Title)----------------------------------------------------------- (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 APPLICATION ACCEPTED BY ---------- DATE---•---- REVIEWED BY - ----------- DATE- BUILDINGPERMIT ISSUED................... ---------------------------------- ------------ ------------------------ DATE-------------------------------- ••------•-- Alterationsand/or recommendations:-------_ ---- --------- -------------_--- ..........................................................•............................................... -----•----------------------------------------- ------•--•- ---- ------------------------------------- --•--------------- ----•----•-.----- ------- ----- - Q� FINAL INSPECTION BY:. Date • ---V------------_ --__-------•-•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North"C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO.