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APPLICATION FOR SANITATION PERMIT Permit No , - ------------ (Complete in Duplicate) t Date Issued Fj Apication 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 Ordinance549..P V , i ^ 1 ff YI JOB ADDRESS�AND LOCATION -J r �� --�------ = F Owner's Name ---- ------ Phone y wr Address-- -- ' ------------- Contractor's Name-- ----- ---------------------------------------------------------- - ------------- one-------------------------------- Ph Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ /Mote) ❑ O her,❑ g • Lot size ----6_0-----��_0f----------------------•-- # Number of living units: _ ___'__ umber of bedrooms __. ____ Number of baths _- Water Supply: Publics stem [VCommunit system Private Depth to Water Table -------- ft. PP Y� Y Y Y ❑ ❑� P Character of soil to a depth of 3 feet: Sand Gravel Sandy Loam Clay Loam E] Clay E] Adobe Q/Hardpan ❑ Previous Application Made: Yes ❑ No V ❑New Construction: Yes /No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic ank: Distence from nearest well--- r�-'------Dist nye frp fo ation_--_/9--_-__-:Mat dial_____________________ _________ _ ( ------------- Siz� ---Liquid uid de th______._._._____ --- - --�---�---------- q depth os�I�Field: Distance from nearest wel!-"""� Distance from found a�tf'F�n,_ _V ___._ Distance to nearest lot li Number of lines_____________ ____ Length of each line_.`f !__ '_ Width of trench_..__ __ t ---------._ _ j Type of filter materia�4-- -- -Depth of filter m ---------- __________Total length--------- 1 ________________.______ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------.-----------Distance to nearest lot line-----_----------- ❑ Nurr ber of pits----------------------Lining material-----------:- ------Size: Diameter--------------------- -.Depth------.---_---------------------- Cesspool: _jwPistance from-nearest well-----------------Distance from foundation--------------------Lining material----_-------__-_.____--_--__-_----_� ❑ Siae;,Diameter--------------------------------------Depth---------- --------------- ---------Liquid Capacity--------------- -----------gals. Privy: Distance from nearest well------.-----------------_-------------------------Distance from nearest building-------------------........---------_----" Distanceto nearest lot line---------------------------------'---------------------_P�-------- --•-----•------------------------------•-------•--------------------------- Remodelingand/or repairing (describe)-------------------------------------------------------•---------------------------------------------------------------------------------------------•--= •--••------------•-•--------•----------------------------•--------------------------------------------------- ----------------------•-------------•--------------------- -------------------------•-= -----------------------------------------•------------------------------ ---------------=----------------------------------------------------------=----------•---------•--------------------------------------------------------------------------------------------------------------------------- .� I tete6y rtL-4ify that I have prepared this application and that the work will be done in accordance with San Joaquin County orc i,ances, State laws, and ruse nd regulations o the San Joaquin Local Health District. F .-(Si ned9 rf F (Owner and/or Contractor) SY:------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------- ---- L '(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__ _.-_ DATE___ __ REVIEWED BY------ - DATE- ------------------------------------------------ BUILDING PERMIT ISSUED---------------- - ---- ------ DATE----------- -------- ---------------------------------------------------------- ---- ------------------------- Alterations and/or recommendations:----------I- ------------ i -=------------ ----------------------------------------- -------------------------------------------------------------------= . +"J It ----- -- ----------------- -- --------------'-------- -------- --------=-- �� -- f i ,- --�. ,..; ----------------------------------------------V it., . er'iw t-. :- N,f ----------- s -�------- ----------------------- ----- --- ---------ie------- ---- ` --------------- ---------------- ------------------------ �--�� - FINAL INSPECTION BY:------ ----------------------------------- Date------,------ ----------- ------------------------------------------ .-------- �' 7-)SAN JOAQUIN LOCAL HEALTH DISTRICT .may 130 South Amencan"Street 300 Wast Oak Street 132 Sycamore Street . 814 Norah "C" Street Stock}on, California Lodi, California Manteca, California Frery, California ;f ES-9-2M 8-51 Revised W-21,00