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APPLICATION FOR SANITATION PERMIT Permit No. -__------"__---- (Complete in Duplicate) r 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 Ordinan bo. 549. JOB ADDRESS AN�0 ON______1�_ -_ _ ------------------------------------- Owner's Name--- --- -----f------ ------ ------------------ ----- Phone.---------------------------------- Address------------------------- -- ---- --- -------------------------•---------------•------ 41410 Contractor's Name-------------------------- ------------- ------- - ----------------- --------------------------------------- Phone-----------°--------•-------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ r Motel ❑ /Other ❑ Number of living units: _ Number of bedrooms _Cn-Number of baths _-/_ Lot size ___!--_____ � l `5� Water Supply: Public system 9?-150mmunity system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob� Hardpan ❑ Previous Application Made: Yes ❑ No;K- New Construction: Yes ❑ No)K FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) OEW) ',ppl i nk=- Distance from nearest well-----------------Distance from foundation-----------__------.Material------------------------------------------------- No. of compartments--------------- ---------Size------------------------•------Liquid depth--------------------------Capacity----------------------- Fi Id: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line____________-_--_ 1 Number of lines-----------------------------------Length of each line---------------------_-------.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------------Total length------------------------------------------ Seepage -----___________________________________Seepage Pit: Distance to nearest well_ -6%4?_ f ndation---.-'7_-�-------Distance to nearest lot line__3 3 Number of pits.___-------------Lining material----V.._ _ _�1___Size: Diameter-----2-3-________.Depth____.4_1r1---------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth---------------------------------- ------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------- --------11----------------------Distance from nearest building------------------------------------------ r-1 ________-.-_--__-_- __.-_ -----_-.._.❑ Distance to nearest lot line________________________ ! r _ y, _ Remodelingand/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, StateI and rules, an regulations of the San Joaquin Local Health District. ----------------------------- ---- ----------- - --- Owner and/or Contractor (Signed) a ( / ' By:---------------------------------------.......--�-il---,_. [�J -- -----------;-----(Title)------ -------------------------------------------------------- (Plot ------------ ----- ------------------- (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ --------------------------------------- DATE-5' ------------- ------------------------------------ REVIEWED BY------------------------------- --- --- ------------------------- ----- ---------------- ------- DATE---cY .------------------------------------------ - - ----- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------V_`----------------------------------------------- Alterations and/or recommendations:_________________________ --------------------------------•---------.--------------•---- ------------------•-------•-----------------------------------------------------------------..._._...__..---------------------------------------------------- ---------------------------------- --•------------------------------------------------------------ -----•---•------------------------------------------------------------ -------------------- •----------•--- -----------------------••--------------------------------------------•-- ----•-- ----------------------------------------------------------------------------------=-------------------------------------------•----•-------- FINAL INSPECTION 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 1.57 F-P,CO.