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APPLICATION FOR SANITATION PERMIT Permit No. -IA-7........... I (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 N 549.- JOB ADDRESS AND LOCATION---3�--�J-----�-----�---------- - --------------------- -------------------.------------------------- Owner`s Name----.--- - ___ - --- -- ---------------------------- - - - - - --_----------------------------------------------------------- Phone----••---------------- Address-------------------- ---- -- -------------------------------------------------------------------------------------------------------------------- Contractor's Name ----------- Phone Installation will serve: Residenc. [ Apartment House ❑ Commercial ❑ Trainer Court ❑ Motel ❑ Other ❑ Number of living units: L______>Mber of bedrooms --'2—_ Number of baths __[---- Lot size O -_-___-_____ 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 L?" New Construction: Yes Pro"No ❑ FHA/VA: Yes ❑ No @'� TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or'cesspool permitted if ublic sewer is available within 200 ft) Septic Septic T - Distance from nearesr well _Distance from foundation-7 __ I Mate is# _ AKNo. of compartments---- ----------------Size__ _ _ Liquid depth____;?------------------Capacify- Disposal Id: Distance from nearest wefi---�,(kll�.Distance from found :on____�_. .........Distance to nearest It �e___ ---______ Number of lines_________ _______ ________L`ength of each line_ Q__S�`� _ _ ,Width of trench___2 _______________________ De th of filter material____.__ _ _._Total len th_____/ a_________________ Type of filter maferial_ ;___- p g __________ 'j Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------------------ Gr #i ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------_-----____------_------ lr� Cesspool: Distance from nearest well_________________Distance from foundation------------------..Lining material-------------------------------------- F-1 Size: Diameter------------------------- ------Depth-----------f---------------------------------------Liquid Capacity----------------------------gals. Privy- Distance from nearest well-------------------------------------------------Disfance from nearesf building______________.________________________._. ❑ Distance to nearest lot line--------- ------------------------------------------------------------ ------ ------- Remodeling and/or repairing (describe):--------- ------------------•------------------------•------------•-----------------------------•-------------------------------------------------------- .j ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ -- ------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. s - -----------------------------------------------------------------------------(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). 1 w. , FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ----------------------------------------------------------- DATE-------------------------------------- } REVIEWED BY-------------------------------------- -- - --- ------------------------------------------------------------- DATE ---- -------- ------------ BUILDING PERMIT ISSUED---------------- --- - - - --------------------------------------- DATE Alterations and/or recommendations: •-------- --------- -----•-------- ----------------•----------------------.------------- -• -----•-----------------------------------------------•------•------------------------------------- -----------------------------------------•------------------------•--------•--------•--------------------.- -- - - - -- --- - - - - -A- c --- - -- -- ---- - FINALINSPECTION BY---------------------------------------------------------------- Date--- -------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Waif Oak Street 132 Sycamore Sfroet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P,CO.