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+y` o I,/Ito . � APPLICATION FOR SANITATION PERMIT Permit No. ��. .{�_ (Complete in Duplicate) //r 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION_ , c. .�. -� ______._____ ____,. Owner's Name------------ s� ----------------- Phone---------•-•------------- Address--------------------------------- -------------------------------- - ---------------------•---•---------.._.-- Contractor's Name--------- ----------------- Phone_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel (] Other ❑ Number of living units: -I?-- Number of bedrooms ____ __ umber of baths _ Lot size -_-- --- _ .__/,j __-_________ Water Supply: Public system IpAcommunity system ❑ Private ❑ Depth to Water Table gvft. I 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 ❑ FICA/VA: Yes ❑ No ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: •CTi ' (No septic tank or'cesspool permitted if public sewer is available within 200.feet.) is Tank distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- No. ____-____-______.________________..___.____._.No. of compartments--------------------------Size---------------•----------------Liquid depth--------------------------Capacity----------------------- / �oF � � Distance from nearest well_� Distance from foundation____-C_91.__r___.Qistante to nearest lot line---- �] Number of lines------- Length of each line_--D___`__ Width of trench____ _e--_____________ Type of filter material_. _ __ p g _____________ De Depth of filter material____ __ ___________Tofial len th___,�---�______ _.__.. Distance to nearest well_ ______________Distance rom f undation__�_d_r_.....Distancflto nearest lot line _*. at VJJL.vr� Number of pits_--j----------------Lining material-- -----Size: Diameter___ c3--------Depth-_-. ------------------ \ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------..__.___.________..___________- Q ❑ Size: Diameter-------------------------------------FDepth----------------------------------------------------Liquid Capacity----•-------- -------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------_______-__________ ❑ Distance to nearest lot lire-------------------------- ------------------------------------------------------------•----------------------------------------------- Remodeling -and/or repair-sng (describe):--------- --------------------------------------------------------------•----•-------------------------------------------------------------------------- -----------------------------•- --------------------------------------------- - --------------------------------__----•---------------•-----------------------•------•-•------------------ •---------- -------- I hereby ce ify at I have prepared this a cation an at the wo k will be done in accordance with San Joaquin County ordinances, State , and rules Mid reguiati of the San aquin Loc I Heict. (Signed)---------------------- ---------•------------ - --------- -------------------- wnContractor) 9!: By=---------------------------------------------------------------------------------•----- ------ ----- Title).- � s----------------- (Plot plan, showing size of lot, location of system in relation to wells, it in - be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------------------------------------------------------- DATE---------------•----•-------------- REVIEWED BY----------------------------- DATE BUILDING PERMIT ISSUED-------------- ------------ ------ ----------------------•-------------------------------------- DATE-•------------------ - - - Alterations and/or recommendation --- -- ---------------------- -----------------------------------------------•-•------•------------.. ---------------------------------- -------------------•----- -----------------------------------------------------------------------•----------------- ------------------------------------------------= -- ---- ------•------•--------------------------•------------ }--------------------------------------------•-- ''� 7 ` ��--------------------------------------------------------- FINAL INSPECTION BY - _______. ._ --•- ----- ---------------------- Date t--� ?. ,.. 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 , Revisea 1.57 F.P.CO.