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APPLICATION FOR SANITATION PERMIT Permit (Complete in 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 Copnty 0r inance No. 549. JOB ADDRESS AND LOCATION___ -------- ----- ______ Owner's Name--------- � -------- ------- - ------------------- ----------- Phone ---- ----------- Address---------------- L14----- �-' -. T� -- -- -- �----------- - - -- - -- - - - --- - - ------ ----------------- ------- Contractor's Name--------------- - - - P ---._. Phone pInstallation will serve: Residence [ Apartment House ❑ Commercial [❑ Trai er Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedroomsz-_ Number of baths __ _---_ Lot size 2 (J Water Supply: Public system P-_11commuriity system ❑ Private ❑ 'Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9+-1�ardpan 0 7 Previous Application Made: Yes ❑ No New Construction: Yes 2-IN"o ❑ FHA/VA: Yes ❑ No P� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well--------------__-Distance from foundation-------------------.Material _________________________________.___________-. ❑ ` No. of compartments--------------------------Size--------------------------------Liquid depth------------- ------------Capacity---------------------- Disposal Feld: Distance from nearest well_ _ Distance from foundation _QDistance to nearest lot line_-�_----_, Number of lines-3------------- ____Length of each line__ - - d�Width of trent 2�l/ Type of filter material-- _---__Depth of filter material___1?_f/________Total length____ --------- -- ---------------- �/ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------.__.__.Distance to nearest lot line_______._________ ❑ Number of pits----------------------Lining material--------------- ---..Size: Diameter-----------------------Depth-------------------------------__ Cesspool: Distance from nearest well_________________Distance from foundation------.-------------Lining material__________________________ ___ __ M ❑ Size: Diameter ----- ----- Depth - -----------------Liquid Capacity------------------- ---gals. "��►► Privy: Distance from nearest well _____------------ --------------------------- -Distance from nearest building_____________________________ - ----------- 171 Distance to nearest lot line---------------------------------t-------------------------_---.-- Remodeling and/or repairing (describe)_----------------------------------------------------------- ------------------------------------------------------------------------------- •_- --------•----------------------------•--------------------------------•---------------------•-------------------------•---------------------------------------------------------------------- ---------------------------------------------- ------------•-----------------------------------------------------------------------------------------------------------------------------I--------•-------------- - 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. (Signed) �_ <= ------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(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 Y APPLICATION ACCEPTED BY --------------- DATE 1�� REVIEWEDBY -------- - - ------------ -------------------- ------------------ DATE----------------- ---------------------- BUILDING PERMIT ISSUED----------------------- -------------_- _ DATE /.__------------- Alterations and/or recommendations:-__ - ------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ----------------- --------------------------------------------------•-•------------------------------------------------------------------- ------------------- ------------ ------------------------------------------ FINAL INSPECTION BY----------- --- ----•-- ----,'--- `--------- -- Date__ �_�-6/0 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 1-57 F.P.CO.