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Permit No. APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 1 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 Ordina ce N 549. JOBADDRESS AND OCATION-- -------------------------------•-------------------------------------------------------------------- Owners Name--- ---------- - -------- Phone-----•---------------- --- -G''-�'�-pro/s_r- -- - -------------- -------------------------------------------- -'-'-'-'- --- Address-------- -- ----------------------------------------------------------------------------------------------------------------- Contractors Name ------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I-___ Number of bedrooms . _ Number of baths ---/__ Lot size _`_ Z�_��-----------------------_.----_ 1. f ' Water Supply: Public system F] Community system ❑ Private ❑ Depth to Water Table y ft. Character of soil to a depth of 3 feet: Sand ❑f Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No n" New Construction: Yes ❑ No ® PHA/VA: Yes ❑ No g---' TYPE OF INSTALLATION AND SPECiF[CATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i Sep c Tank: Distance from nearest well-----------------Distance from foundation-------------------Material------------------------------------------------- No. of compartments __________ ---- p -----Size-------------------------- Liquid depth--------------------------Capacity----------------------- _ Dispos •Field: Distance from nearest well-------------_-.-Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line--------____----____----__---.Width of trench-------------_--_-- �. o Type of fifter material-------------------�--_-Depth of filter material-----------------------Total length---1_ - `_ ' -_-- i ` / - e Seepage Pit: Distance to nearest weli__�>9�__-------Distance fc�oom�m�f ndation---��..___.Distgan jre to nearest lot line---1A--_-- Number of pits----- ------------ Lining material__,e'1'�"----.Size: Diameter----.?�.?- __ Depth----1 � ` Cesspool: Distance from nearest well-----------------Distance from foundation--------------.-__..Lining material--.___-----________-__________----- v ❑ Size: Diameter---------------------------------------Depth------------------------------------------------; Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well--------------------_---------_--.---_---------Distance from nearest building----_--__--------_--------_------------. �I i ❑ �l Distance to nearest lot line- - --------------------------------•------------------------------------------------------- Remodeling and/or repairing {describe) ------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------- -------- ----------- ------------------------------------------------- - ----------------------------------------------------------------'---....-------•-•---=----------------------------------------- —------------ ------ --------------------------------------------------•---------- --------•----------------------------------------------------------------------------------------------------------------- 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, anq ru"andretions of the San Joaquin Local Health District. (Signed)-------------- -~ --- - ---- --- f '�o+ Contractor) (Title) Y:--•-----------------------------------------•-------- -------- --- (Plot plan, showing size of lot, location o ystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -- - DATE--�----------------------------------- ---------------- REVIEWED BY �- DATE-�-- --- - BUILDINGPERMIT ISSUED------.-•--•---------------------------------------------------------------------------------------. DATE----------�--------------•----- Alterationsand/or recommendations:--------=--------------------------------------•--------------------------•--------------------------•---------•--------------.--•-- ---------------------------------- -----------n------ '---------- ------------- ---- - - -- --------------- -- --------- _ --- ----- ---- - -- - --- -- - -- - ---------- r� +�- 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 Revised )-57 FY.CO.