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APPLICATION FOR SANITATION PERMIT Permit `b_ ' ... [Complete in Duplicate) ` Date Issued l_________________� Applicaa-ion is hereby made to the San Joaquin Local Health istri t for a permit t struct and install the work herein described. This application is made in compliance ith ounty Ordinanc No 549. � � 1 C_.2 JOB ADDRESS ND LOCATION___________ _-___ . - ` �( Owner's NameL i SI- `_---- `s --, - Phone ' ��i Address._..__�7_ _,_e---------------------- -y--- --- -----------------------------------------------------------•-----•-------------------------- Contractor's Name------------------------------------ ---------- ------- Installation will serve: Residence ❑ Apartment House ❑ Commercial 23-1—railer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ------- - -------------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil too depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: YesJ�CNo ❑ New Construction: Yes ❑ No ❑ � ��– TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) ti T Distance from nearest well______-----_____Distance from foundation___________________-Material__----_-___-_-.________---. p --------------------- No. of compartments--------------------------Size---------------------------- ---Liquid depth--------------------------Capacity----------•----------- osal Fiel ;� Distance from nearest well------------------Distance from foundation__------__.-____-_-Distance to nearest lot line-------------- ' Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material_______________________Depth of filter material-----------------------Total length____.---_-____-_________-__----__________ See a Pit: Distance to nearest well.. c^____Distance fr m foundation_.1–S/Distance to nearest lot line-----4 Q--- Number of pits----- ----------------Lining material- _ -- ---_-lj---- -_ N------Depth-f�.,40.1 ----------- Cesspool: -- ---- -Size: Diameter-_-��_.__ Cesspool: Distance from nearest well-----------------Distance from foundation----------------___Lining material-----------------------------------_. ❑ Size: Diameter-------------------------------------Depth-----_----------------------------------------------Liquid Capacity----------------------------gals. . . Privy: Distance from nearest well------------------------------------ ------------Distance from nearest building------------------------------------------ F1Distance to nearest lot line-------------------------------------------------------------------•----------------------------------------------------------------------- Remodeling and/or repairing (describe)---------- ------------------•--------- ----------...------------------•-------------------------------------------------•------------------•------------- ------------------------------------------------------------------------------•------------------------------•------------------.....---------------•----------------------------....---------------------------------------- I here cern y t I have prepared this application and that the work will be done in accordance with San Joaquin County ' ordinance State laws, nd rules and reg tions of the San Joaquin Local Health District, -------------- (Signed) -------------------------------- ------- ---- -----------------•------------------------------.... --- ontractor) By:----------------------------------------------------------------------------- - ---- ---- --------�----- -----------[Title} ---'^------------- (Plot plan, showing size of lot, location of system in relate to wells, buildings, tc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ f ------------ - - ---------------- DATEr --------------------------------------------- --------------------------------------------------- -- -- - REVIEWED BY-------------------------------- ... ... - ----------- ----------- ------------------------------------------------- DATE-.:-------------- ------------•----------•------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE...... --------------------------------------- Alterationsand/or recommendations-------------------------------------- ---------------------------------------------------------------------------------•------------------••------------------- ----------------------------------------•-------------------------------------------------------------------------------------------------------- -------------......----------------..-..---------------------------------- -----------------------•------------------------------ ---------------------------------- -----------------------••------------------------------ ---------------------------- •------------------------.------------- ____________________________________________________________________ -------------------- -------------------------- . � r FINAL INSPECTION BY:. ---- --- ----- hate 4 - ��". ._. --- ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak S+raef 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California FS—q-7m : IRevised W-4l00