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APPLICATION FOR SANITATION PERMIT Permit No. _ 7�'7-____ (Complete in Duplicate) 3 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 LOCATI 7_- -- ----------- ------------------------- ----------------•---•-------•--------------------------------------------------------------- Owner's Name---•------- C,--------- - - ------------------ Phone.----•---------------------------- Address---------------------� ; -------•----"-�------------------------------------------------------------------------------------ Contractor's Name - - ----------------- Phone--------------------------- - - � -------------------------------------------------------------------------- Installation will serve: Residence [��Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of livunits: ________ Number of bedrooms __/-_ Number of baths -------- Lot size ______________________________________________________.__ Water Supply: `i ystem ❑ 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 [�lew 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-----------------Distance from foundation-------------------Material___-._________.___._---_-_-________-___.-_____-.. ❑ No. of compartments- -----------�-----------Size---------------•--------•--- -_.Liquidpeh.......-....--------------Capacity-------- Disposal Field: Distance from nearest well__Yn _ �-Distance from foundation_______________Distance to nearest lot __-_..... t � Number of lines---•--------/------- -- - Length of each line-------�d-------------Width of trench-.__-�.Z/----------------._-- Type of filter material_ ` ' Depth of filter material-----------------------Total length--- ength__ ��------__--_-___________-_.- Seepage Pit: Distance to nearest well_. Distance from foundation........ ` f31s}a�nce to nearest lot line-- Number Number of its_____./___----_----Linin mat Size: Diameter______.��_---_- - s ®•�� p g -Depth--- --�-- -�- ------------ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material--..___-____-____________________-_. ❑ Size: Diameter--- ----------------------------------Depth----------------------------------------------------Liquid Capacity----------------------- Privy: Distance from nearest well---_---------------------------------------------Distance from nearest building--------------------------_------.-----._. q ❑ Distance to nearest lot line------------------------------------------------------------ -------------•------------------------------------------------------------------ !" t—fRemodeling and/or repairing (describe):_____ __.____ "d � "' ---------------------------------------- -------------------------------------------------------------•-------------------------------•----------••------------------------------------------------------------------------------------------------------------------- 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 and regulations of the San Joaquin Local Health District. ed). , ------ - -- ------- --- _______________(Owner and/or Contractor)(Si n .__-__ -= --- B . ' --- --- -- -- --- --- ---- -----------------------------(Title)----------------------------------------------------------- (Piot plan, showing size lob, location of system in relation wells, - ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- ----------------------------------------------•-------------------- REVIEWEDBY------------------------------------------ ------ ------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED.......... -------------------------------- --------------------------------------------------------- DATE--------------------- Alterations and/or recommendations:--------------------------- -----------------------------------------------------------------------------•-------------•------------------------ ---------•--------•---------------------------- --------------------- --•.-----------------------------------------------------------------------•--------------------------------------------•----------------------------- -------------------------------------•-•----11------------------------------------------------------------------------------------ ------ •----•-•------------------------------------------------------•-------------- ---------•------------------------------------------•----------•------------------------------------------------------------- ----------------- 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 E5-9-2M Revised 1-57 F.P.CO.