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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) S 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------------ ( ��_____ --- --- ----------------------------------------------------------------------- ------ Phone- -----------------------------•--- Address1-------------- -4-------- Contractor's Name----------- ------ ----------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot��el E] Other E]Number of living units: /---_ Number of bedrooms _ Number of baths __/__ Lot size ----41.ot/Y_ix-_-lA1v_�____________________ Water Supply: Public system [Community system ❑ Private E] Depth to Water Table _ZAP ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ??'0-New Construction: Yes ❑ No [ FHA/VA: Yes ❑ No 9�-' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i ,pSepji ,ank: Distance from nearest well-----------------Distance from foundation--------------------Material____________-_______-_________-_____________.__. 9 (jYt, No. of compartments------ ------------------Size--------------------------------Liquid depth---------- ---------------Capacity_...-------- ispo Field: Distance from nearest well--.--- ---------Distance from foundation--------------------Distance to nearest lot line______________--- A Number of lines___________________________________Length of each line.___- ------------------- Width of trench----------------------------------- Type of filter material-------------------------Depth i ter erial------ -------------__Total length------------------------------------------ See a e Pit Dis#ante #o nearest well__ I'/___�Di ante f om f n ation_ A -__------_ p g /1 _-_ _�__.Distanc�e to nearest lot line`- � V) Number of pits____-------------Lining terial_ _ Size iameter_._ �_ p Cesspool: Distance from nearest well_____________ ___Distance from foun ion___-----------------Lining materiaL____________________________________ ❑ Size: Diameter------------------------ --------- ---Depth----------------- ---------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well________________ _______ ----_-_------Distance from nearest building------------------------------------------ 0 __-____________________-__----_ ---_----.❑ Distance to nearest lot line ________________________ Remodeling and/or repairing (desCrisbe): _ez --------- ---------------------------------------•------------------- -----------------------------------------------------------------------------------------------------------------------------------------------••---- -----•---------------------------•------------------------------------ --------------------------------------------------------=--------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules nd regulations of the San Joaquin Local Health District. (Signed)------------------------ _----------- --------------(� Contractor) gY� ------(Title) /Fl ' -- ----- -------------- By: plan, showing size of lot, location o stem in relation to wells, buildings, etc., can be placed on rever side). FOR DEPARTMENT USE ONLY S 7- 3: APPLICATION ACCEPTED BY ---------------- -------------------------------------------- DATE_ ------------•-------- REVIEWED BY----------------------------------------- --• ------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------------------------------------- --------------------- DATE Alterationsand/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 Revisaa 1.57 F.P.CO.