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CC�� ✓ ll t APPLICATION FOR SANITATION PERMIT Permit No. ----- f ' J (Complete in Duplicate) �/ �y Date issued ..... __z1s_?-- Application is hereby made to the San Joaquin Local Health District for a permi4ttonstruct and install the work herein described. This application is made in compliance with County Ordinance 49. JOB ADDRESS LOCATION--------- ------ -- ------------------------------- Owner's Nam - -------------- ---------- ----- Phon Addres _._ __ _-__ --- Contractor's Name----...•--------- ---------------- Phone;Vi, �1A Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Number of bedrooms-- Number of baths__ Lot size -----�7-J----r__: /4. 7__ r Water Supply: Public system[ .community system ❑ Private ❑ Depth to Water Table S _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No �FHA/VA: Yes ❑ No ©�~ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) S tic nk: Distance from nearest well-----------------Distance from foundation-__.--____-__.-_-.Material-_---__-----._.___-___--_-_----_--_-..._.__.___.. No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-•--------------------- Disposal Fiel Distance from nearest well-----------------Distance from foundation-----------------_Distance to nearest lot line__--_---___.----_ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------- ____ _____Depth of filter material______________________Total length__----------_-__--_---____---_--_----_-._ Seepag it: Distance to nearest well_- __._ l�/ istan�eI fo dation__/f _____.Distance to nearest lot line----- ^-�__- IF Number of pits____ ______________Lining material_- _____.._Size Diameter_0,3__'__..__Depth___ - -______.__-_____ Cesspool: Distance from nearest well----------------- from foundation-------------------.Lining material------.____-___-----_-__.____._____._ ❑ Size: Diameter--------------------------------------Depth----------------------------------------- ------Liquid Capacity-----------------------------gals, Privy: Distance from nearest we€I--------------------------.--___:----------------Disf6nce from nearest building--..___.____----___----_-_________.___,_-. (� ❑ Distance to nearest lot line--------------------------------------------- -----------------------------•---------------------------------------- Remodeling and/or repairing (describe)------------------------------------------------------------ --------------------------••------------------•---- ----- -- ----•----•------------------------------- •-------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------- I hereby car ' th` I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat la s, a d rules ari<d r gulati of the San Joaquin Local Health District. (Signed) wner and/or Contractor .�._.. --- --- - "��`f� ----- -- -- - -------- By----------------------------------------- � - {Title) --•------------------------------- (Plo} plan, showing size of lot, location system in relation to well buildings, etc `can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ---- .,--------------------------------- ---------- ----------------------- DATE.---- ----•-------- REVIEWED BY-------- - ------------------- ------------------------ ----------------------------- DATE------- -- BUILDING PERMIT ISSUED--_------------ -------- --- I --------- DATE-----------_-- a Alterations and/or recommendations------ -- ---------'- •- - ---- ---------------------------------------------------------------------------------•---------------------•------------------- -------------------------------------------------•-_---•----=------------------------------------- ------•-----------------------------------------------_----•-•-----------------------------------•----------------- ------------------- ---------------------------------------------------------------------------------------------------------------------------- -- � j �f s FINAL INSPECTION BY:-------- "' Date--- ( ---ref-- --y�---------------------------------------------------- // J SAN JOAQUIN LOCAL HEALTH DISTRI T 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 FY.CO.