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APPLICATION FOR SANITATION PERMIT Permit No. ...//________________ --" (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...... �j -° -----••------------------------------------------------------------------------•----- Owner's Name----- -------- , ►--------- ------ Phone--------------------_------------- Address--- •-------- l Addressjd' �� d' ---- ---•----•- •--------- -••-------------- 6 � _. Nv„ ----------------------------------- Pcone ------ -------•------- Contractor's Name---- Installation will serve:..Residence ' Apartment House -Commercial ❑ Trailer Court”❑• -Motel ❑ Other ❑ Number of living units: ---------Num"ber" __---__,Nurrber of bedrooms::.._-- Number of baths __/___ Lot size ----- -------------------------- Water .Supply: Public system C—bmmunify 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 ❑ Noy, ' New Construction:. Yes ❑ No ❑ FHA/VA: Yes ❑ No.❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - "`' I (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest.well---------------':-Distance4from foundation----------------.-_.Material_----____--_._.._______________________.._.____- No. of compartments!_ Size------------------------__ ❑ P - ------Liquid depth--------------------------C?.pad!'Y----------------------- Disposal'Field..,- ----- -- -- -- --- Disposal'Field:, Distance from nearest-well--------------�4-_Distance from foundation-------------------.Distance to nearest lot line________________" �} ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----------------------------------- Type of filter material-______________________--Depth of filter material------------------------Total length------------------------------------------ (A) F Seepage Pit: Distance to nearest well_____ Distance from foundation to nearest Sot line_,";9 ' Number of pits___-____�___- Lining material- Size: Diameter______ _-1_.____.Depth_�o_ 0__._f_--______________ Cesspool: Distance from nearest well-________________Distance from foundation---------------------Lining material-------------------------------------- ElSize: Diameter ------------ Depth =------------ --'----------------Liquid Capacity- - ------------------------gals. c Privy: Distance from nearest well--------------------------------------------------Distance from nearest building--___...______.____________________.____. ❑ Distance to nearest lot line------------------------------------------------•------------------=------------------------------------------------------------------------- Remodeling and/or repairing {describe}---- -------------------- = ---------------------------------------------------------------------------------=--------------------------------------------------------------------------------------------------------•----------------------------------- --------------------------------------------------------------------=----------------------------- C ------------------------- ------------------------------------------------•-------...-------------------------------------------------------------------------------------------------------------------------------- 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. 1� 1 (Signed)______ _ I'?/ �s_______.._ -----------(Owner and/or Contractor) By:--------------------- ---•------------- y--------------------- ----------------------------- ----------------- ----------(Title)-- -- -------------- (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- !�.p �.---__-______-_-_____--__-_ -----------•------------------------ DATE--------------RP?n` ---- ----------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED--------------------- •--------------------------------------- ------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations-----------------------------------------------------------------------------------------------------------------------------------------------....".._ -------•--------------- -+--------- - - ------------------------- ---- ---' - ---------._.-.-=----------------------------•----- -- ------------------------------------------------------- ------------------------------------------------------•----------------------------- --------------------------------------------------------------------------------------------------------------------------------------- -----------------------•-------------------------------•- ---------•----------------------------- ------------I - FINAL INSPECTION BY:.,_e�:--- -`- fir` ` "-.---------- Date---- - ---3__" ' b SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Americdn Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E$-9-21v1 Revised 1.57 F.P.CO. t