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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ._ bh 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. JOB ADDRESS AND LOCATION--------- _ ______________________ .._ ...� l ------------------------------------=-------------------- Owner's Name------------- Phone------------------ - -------- ------------ - --------------------------- Address-- ----- - , -------------------------------------- --------------------------------------------- Contractor's Name-------- - ---------- --------------------------------- Phone.----- ----------------•---------- Installation will serve: Residence [�J--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J_-___ Number of bedrooms -;?-- Number of"baths _/_. Lot size __ cle � __ -__._�__.1. 7= ------------------ Water Supply: Public system Sj_.Community system E] Private Private Depth to Water Table Cft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,[] Hardpan ❑ Previous Application Made: Yes ❑ No �" New Construction: Yes ❑ No�HA/VA: Yes ❑ Nom_ TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: istance from nearest well------ Distance from foundation---------------------Material____.___----________-._-_-________---_--_____. ❑ 25; o. ld: compartments-- -----------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal FieDi ante from nearest well----------------'Distance from foundation--------------------Distance to nearest lot line-------------.__. ❑ of lines-----------------------------------Length of each line------------------------------Width of trench.--------------------------------- Typ of fi{ter material-------------------------Depth of filter material-----------------------Total length-----------------•-_---------------------- Seepage Pit: Distance to nearest well--- _«`- _Distancom foundation__r�_-____-.Distance to nearest lot line---/a`__ Number of pits----- -------------Lining material--"-.- _-Size: Diameter--- 7� Deptn____c�z _w---•---------- Cess�pool: 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--------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):---------------------------------------------------------•---------------------- ------------------------------------------- ---------------------- ------------------------------------------------=---•----------'--•--- ----------------------------------------- ---------------------------------------------------------------------------------------- ------------------------•-----------------------•--------------------------- -------------•--------•------------------------------ I hereby certiawf that I have prepared this application and that the work will be done in accordance with San Joaquin County, ordinances, St a , and rules and regulations of the San Joaquin Local Health District. -- Or and/or Contractor) (Signed] -------------- -------- ' --------------- ------ #- ---------�- -----( - sBy: ----- -----------(T'tle) (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 REVIEWEDBY----------------------------------- --------- ------ -------------------- --------------------------------------- DATE BUILDING PERMIT ISSUED -- DAT ------------------------------ \ - - Alterations and/or recommendations: -------------------------------------- -• --- -------- ---------------•--- � ---- - - -- ------------------------ ------- -------------•-•- ------------------------ / ---------- ------ ----- - ------�--��---- - -- ----------------------------------- ----- -----------------------•-•------ -- - - - - -- - -- -- --------------- --------------------------------------------------------- --------------------------- - - 77 C — - Date_ ~---- .1-._.""t...]------ ------------------------------------ F1NAL INSPECTION BY:---- ------ -- ------ ----- -= --------�---------- - 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-9-2 - Revises 3-57 F.P.CO.