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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) y r� Date Issued ---------�__S� ' Application i's 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`.x` JOB ADDRESS AND , LOCATION-- -- ------- ---- ---------7----------- � J- -_=------------------ --------------- - --- - Phone-------------------------------- Owner's Name-------- ----__1541,; Address___. .----------- --- -- i Contractor's Name----------------------------------------------------------------------------- --------------------------------------------------------------- Phone----------------------------------- lnstallation will serve: Residence . Apartment House ❑ �mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- number of bedrooms A3--- Number of baths ---/ _ Lot size C0______________________ Water Supply: Public system D�, Community system ❑ Private ❑ Depth to Water Table -------- ft. 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 X No ❑ PHA/VA: Yes ❑ 3 No TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or'cesspool permitted if public-sewer is available within 200 feefl Septic Tank: Distance from nearest welDistance�fro foy��ationr -_I------_____ Materi I__ ALfte- -------- No. of compartments ---_- --Size---`., a---:_'_Liquid epth---_______ .. Capacity- ---------- Disposa Field: Distance from nearest well_ __AaDistance fromcfoundation1 __fi -----.Distance to nearest lot li . g tr-------------- Number ----• Number of lines---------- ------ - Length of each line______-_¢- Width of trench------- ----+ Type of filter materi itL. Yp � -Depth of filter material-----f--il-6.........Total length-----------;----Q---------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation_------------------Distance to nearest lot line----------------_ ❑ Number of pits----------------------Lining material-------------------I---Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-)-----------------Lining material--------____---____-_______--------. ❑ Size: Diameter------------------------- ------Depth-----------.------ --------------i- ----------- Liquid Capacity----------------------------gals, Privy: Distance from nearest well---------------------------------------------.___—Distance from ,nearest building___-___-----------_-_-___-_________-_____ ❑ Distance to nearest lot line------------------ 1 -------------------------------------------------------------------- i Remodelingand/or repairing (describe)------------------------------------------------------------------------------------- ----------------------------------------------------------------- ` --------------------------------------------;-------------------------------------------------------------------------------- =------=----------------------------------------------------------- ----- m -------------------------------------------------------• -----------------------------.----------------------------------------------------------------------------- -------------------------------------------------------- k l 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 roe ulations of the San Joaquin Local Health District. : -------------------------- --------------- ------- wner and/or or Contractor (Signed) { / -------------------- ----- 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 APPLICATION ACCEPTED BY------------ -_ DATE____--.=y- --- -------- - -- -- - REVIEWED BYP DATE--- --- BUILDING PERMIT ISSUED---------------------------------- ---------------------- ------ DAT ----------------- ------------ ------------ AI erWoand/or r mm ndations:__ --- -- -- --tom--------------- ^-- ----- - ----- ------------------ - ----------------------------------------------------------------------------------------- - ----- ----------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- -------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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-7-2M Revises 1.57 F-P.CO.