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APPLICATION FOR SANITATION PERMIT Permit No. ___ l/---- (Complete in Duplicate) --------- Application - 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,. �a JOB ADDRESS AND ATION------ / = -- -- -- ------------ ----------1----------------------------------•- - -- - -- -- - Owner's Name - t//. ..... -- - Phone Address_____C--- -- q� - f -- C --• o Contractor's Name__ ._ ___. Ph ne _ ----- - ------ -- - - ------- -- - Installation will serve: Residence 8 Apartment House ❑ Commercial ❑ Trailer.Court ❑ Motel ❑ Other ❑ Number of bedroom,,-"?- Number of baths _ :+I'Lot size .""� "� Number - ---of living units: /-- - ----f-f• -, � _ Water Supply: Public system IN Community system [I Private ❑ 'Depth to Water Table �_Dft, r Character of soil to a depth of 3 feet: Sand F] Gravel ❑' Sandy Loam ❑ Clay Loam El Clay ❑ Adobe Hardpan E] ' r Previous Application Made: Yes ❑ No New Construction: Yes El No - FHA/VA: Yes ❑ No ❑ r- AC TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) I ] m -•------•-•--•----------- Se ----- Sepis Tank: Distance from nearest I - Mtil � iSize--------------------------------Liquid depth--------------------------Capacity_--------------"------- No. of"compartments__-___-_______. is `y s Field: Distance from nearest well_ ___:____.. Distance fr6m foundation_____---------------Distance to nearest lot line_____--_,________ ------------------------- Number of lines---------------------I----- --------Length of each line-----------------------------Width of trench. ' Type of filter,material _1--------- Depth of filter material__-__-_--:.-__^_- -Total length-----------------•------------------------ - r ! _-- _ .�-•------.Dis#an�ye to nearest lot line. _-- Seepage Pit:_ Distance to nearest well --__Distance m I ndation_. ----.De th .S!_' a Number of pits._.__, -`--]Lining materia _________ _ ____Size: Diameter- ��----- p V -.i► . Cesspool: Distance from nearest well-----------------Distance from foundation_:"___________ Lining mapacil___.__._.____...___________-_--.____. Size: Diameter----------------------] --- -----Depth r - Liqu d Capacity gals. tPrivy: Distance frorn nearest'well_ --------------------------- stance from nearest building'____________.__--__--_----.------------_ ❑ -- ;:. ,..._. _ Distance to nearest lot line-----------------------------------------------�---- --------------------x------------------------- ----------------------------- - -----------•------------------•--- ------------ -._, Remodeling and/or repairing (describe}:--- _ - •-------•------------------ - ---=-------- -------------------- - -----•----- t ] i -- ---r---------I-------------- ------------- ---------------------------------------------------------_- ------------------= ti ---------------------•--------- ----------- "--------------•----------------------------•--------- ------------------------------------------ --=--------------•----- ------------------ --------------------:---------------------------------•----•------------------------------------------------ I herebya ertify that I have prepared flfis applicafion and+hat fh work will be done in accordance with San Joaquin County r ordinances, tat laws. and r and r'egulat' ns of San Joaquin Lo l Health District. Si neo _ r -------_ wrier and/or Contractor] 5 } -- --- � --------(Title]--- (Plot plan, showing size of lot, location of system in elation to we buildings, etc.,'can be placed on reverse side]. FOR'DEPARTMENT USEONLY APPLICATION ACCEPTED BY----------------------- DATE----------- _-- ----------- f '10 IDATE =-- ! REVIEWED BY---------------------------------------- - ---- ---- - ----- ------------------------------------------------------------ - ------------------------------------------- BUILDING PERMIT ISSUED-------------= ------ -- -- ------------ iDATE. 1 - , w Alterations and/or recommendations:___" ------------• ---•------ -- -- --- ----- ------- ------------- 1hfl?tr_ ` ' ---�u�----�`ro /y r! `A cit -------fir— z"Ae--------------- { -----'•--_r'Q , ----�lT !J- /._OfJ------ -V'----- � - --------'---------•--- -•- --- -- - -- - -- - - ----------- ------ ---------------- ----•• -- --•---- 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 , Revised1.57 F.P,CO.