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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) 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 Ordinance No. 549. JOB ADDRESS AND LOCATION------- ( '-.......... ------- ".---- -----------------------------------------•---------------------------- Owner's Name------------ Address ------- - Phone r Address------------ -- - ---------•----------- -------- -•----- ----------------------------------------------------• ---------------------------••---------------------------------------- J Contractor's Name----------------------- - -- - - Phone.. Installation will serve: Residence Apartment House ❑rCommercial L] Trailer Court El Motel ❑ Other El Number of living units: _,/-__ Number of bedrooms _ Number of baths 4-- Lot size ---------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table /�Z ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] San dy Loam ❑ Clay Loam ❑ Clay E] Adobe[ �ardpan ❑ Previous Application Made: Yes E] No PRO"New Construction: Yes ❑ No PR— FHA/VA: Yes ❑ No R;-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) f ptic nk: Distance from nearest well_________________Distance from foundation--------------------Material______.___________________________-.---_-_-____. p Size------------------ Liquid e�t�.Distance to nearest lot line---------------- No. of compartments q p. Capacity-- spos fiello d: istance from nearest wek--_ Distance fr"r'i foundation______ _--- a Number of lines------- _________ ____Length of each line_.___"__ _- ' ----------Width of trench----- -, --------------------- ----- ------------ • Type of filter material__ -_-Depth of filter material Seepage length_________ t �_________________ Seepage Pit: Distance'to nearest well----------------------Distance from foundation___-----------------Distance to nearest lot line__.______________ ❑ Number of pits----------------------Lining material------------------_----Size: Diameter--------------- ---- Cesspool: Distance from nearest well-----------------Distance from foundation.___------___.____.Lining material------------------ 1 _______.__ ❑. Size: Diameter----------- --------------------------Depth----------------------------------------------------Liquid Capacity--- -------:----------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest-building----------------------------- ❑ Distance to nearest lot line--------------------------------- ------------------------ -------------------------------------------------------------------- ' ------------------------------------------------ ------- Remodeling anti/or repairing {descrilae�_______________________ _- -----------•--------------------------- --•-:-----------------------------------------------------------------=-= ----- 1 f , -----------------------------------------------------------------------------------------------------------------------------------------------------------=-•---------------------------------------------------------------- -------------------------------------------------------=----------------------------------------------------------------------------------------•-------------------------------------------------------------------------I- 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 pnd regulations of the San Joaquin Local Health District. ----- (Signed) (Ewell-,aa>�gGor Contractor ----------------•---- Sy=---------•-------------•--------------------- -- - ------ -------' •---•-•----------- ------(Title) "'--- ---------------- i (Plot plan, showing.size of lot, locat' of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_-- -- DATE-:--------------------------------------------------- DATE--' ------------------------------------------------------ VREVIEWED BY = t ------------- DATE------ - BUILDING PERMIT ISSUEQ - - 2^� ; Alterations and/or recommendations-------- ----------------------------------------------•-------------------------- ----------------4ZPa--.-..._........•----'------------------------ ----------------------- ----------------------------------------------------------------------------- ------------------------ -------------------------------------------------•----------------------------•----------- ------------------------------------•----------------•---•------------------ ---------------------•-----------------------------------------------------• ------------------------------------------------------------------ ------------------------------------- --------•- ---------------------------------- -------------------------------------------------------------- ----------------- ----------------•------------------------------------•-`------------ --------------�------------------------------------ FINAL INSPECTION BY:. - - --------------- Date--- f SAN JOAQUIN LOCAL HEALTH DISTRICT a / 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-21x1 , Revisea 1-57 F-P.CO-