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APPLICATION FOR SANITATION PERMIT Permit No. ' - (Cori'tplete in Duplicate) Date Issued `f This Permit Ex fres 1 Year From Date Issued T 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, S49. JOB ADDRESS AND LOCATION- __ ------------ ------- X ------------------------------------- Owner's Name , �c ------ Phone------------------------------------ Address------------------------ Contractor's Name - •--------------------------- ----- It-----------------------"----------------------- Phone----------------------------------- Installation will serve: Residence M--XPHouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] Number of living units: __/__ Number of bedrooms� Number of baths /___ Lot size _.. _ __ `,'� _________________ Water Supply: Public system ©Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sa}ndy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 'Hardpan ❑ Previous Application Made: Yes ❑I No 0--New-Construction': Yes El 'No Q-- FHA/VA: Yes ❑ No El.,TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) ja k: Distance from nearest Se is well___'_____________Distance from foundation--------------------Material-_------------------_______________..._____-_. No. of compart#encs------------- ------------Size--------------------------------Liquid depth---------------- ---------Capacity-••-------------------- Di pospl Fiel Distance from nearest well...................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_____.____--__-.____--_______________-__ Seepage Pit: Distance to nearest well% .. _ Distanc9matul dation---FS---------Distance to nearest lot line_/�........ Number of pits.______.______Lining material__ Size: -3 -------------- Dept ------------------- Cesspool: Distance from nearest well--_________._._Distance from foundation.----_--------------Lining material_-________________..____._____.______ ❑ Size: Diameter ----•-----------------------------Depth--------------------------------------------------_Liquid Capacity---------------------------gals, Privy: Distance from nearest well---------------------------------------_---------Distance from nearest building-----------------------------------------. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------- ------ f - F Remodeling and/or repairing fdescishe):-- -----------------------------------------•--------------------------------------•-•----------- ------------------------------------------------------ ------------------------------------------------------------=------------------------- ------------------=------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------•-------------------------------------- I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to a ws, and les an egulations of the San Joaquin Local Health District. �`___ _. �-- Owner and/or Contractor (Signed) ----------------- - -- / } By:---------------=--- (Ti+le) ----- - -------- {Plot plan, showing size of lot, location of system in re ion to wells, buildings, etc., can be placed on reverse side). f --- ( FdA DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ----------------------- DATE------- --` ------------ - ----- ----- ---------------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE - ----------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- / - r --- ---- ----------------------------•--•-------------------------------- �� -----`-�-�=----- ---- ----------------------------------------------------------- --------------------------------------------------------- an or recommendations __ ____________ -----•-------------------------------------------------•- •--------•-----------------------------------------------------------------------------------------------------------------------------------•-----•--------------- F _____________________________________________________________h_________.____.__._.________..___________.______._.________-______.___._._______-._._.__-__-___.-__________._______.._____.._-..-...----------_-________.._._____ I FINAL INSPECTION BY:-e------ -----/ ------------- ""-- Date----------_J�_ __-3 �'~ O ` 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 Revised 8-'59 F.P.Co.