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APPLICATION FOR SANITATION PERMIT Permit No. (c6mpleOin Duplicate) Date Issued Application is hereby made.,fo the San Joaquin Local Health District for a permit to construct and install the work herein described. c This application is made in ompliance'with County OrdinancgoNo. 549. JOB ADDRESS AND LOC T PN___.--- - ----------------- ------- ------------- ------------------ --------------- Owner s Name---- ------------------------:------------------------- ------------- Phone-// Addressd . --------------- --------------------------------- Contractor's Name------------ --------- ------- ---- -- ----------- - ----------------------------- ------------- Installation will serve: I Residence gj--�Xpa4menf Housel ❑E] ❑Commerci�[ [_1 Trailer Court [-] Motel El Other El urn e f Number of living units; -/--.,Number.'r o"bedrooms -o-2-Number of baths �Lot size -&;W ------------------- mun.i ty-system,.?% Water Supply: Public system ��eom` E] ❑"Friva WE] b6 pth'forWM6r Table _4/474. Character of soil.fo a depfh"of 3 feet: Sa-nd E]- Gravel E] Sandy Loam E] .-Clay Lo'am El-' Clay El Adobe gi—Mardpan E] Previous Application Made: 'Yes El No E--New Construction: Yes Ej; No ©4FHA/VA:.Yes 0 No E.4— TYPE OF INSTALLATION AND SPEC IFICATIONS (No septic tank or"ces5pool permitted if public sewer is available'wiihin 200 feet.) e tic Tank:. Distance from nearestwell-----------------Distance from foundation- -___ Material--------------- Al ------------------- ---------- No. of compartments_.:------------------- S' --- ize------------------- -------Liquid 'de&h--------------------------Capacity--------- -------------- J�kpos 1 Fri : Distance from nearest�well------------------Distance from-foundation------- A_ ------Distance to nearest lot line_________________ t : Number of lines----- ---------- ---------------:-Length of each - ---------Width of french Type of filter Depth of filter �naf;rial------- L --------- ------Total length_______-___________.__._--____----------- e ___Distance ..L Disfan..ce Seepage Distance to nearest fo dation___ ------Disfahce to nearest lot lin ---- EP� Number o� pits-,./----- Lining material_ Size: Diamet;r---- Dept h.-,g 4- Cesspool: D j stance from nearest-wel[----!-------------Distance from foundaf;on------- ------Lining material----------- El Size: Diameter------- - L -------------------------- ------- --------------------Depth--------------------------------- -------: ------Liquid Capacity"-=------- I -----------------ga s. Privy: Distance frorri nearest4well_- .... -----------------Distance from nearest building__.____ ------------ rl Distance to-nearest-lot-line_-__,__.________-_____ -- -------------------------------------------------------------------------------------------- Remodeling and/or repairing' (descriN).-___' ;--- ----------------------------------------------------------------------------------------I----------------------------------------- -------------- -------------------------------------------------------- ------- !--------------------------L----------------------------------------------------------------------------------------- -------------- --------------------------- ----------- - ------------------------------------------------------- - ----------------------------------------------------------------------------- ---------------------------------------- ----------------------------------------------- --------------------------------------------------------------------------_--------------- ---------------------- ------------------------------------- I hereby certiTf that ],-have'prepa're�d this'application and that the work Wjlj'Lbe-done�in accordance with San Joaquin County ordinances. State pw ;and and nd re ulafrons of the San Joaquin Local Health District. (Signed)------------------ ----------------m------------- -------------- ------ ------------- --------- {Owner and/or Confractor) By:--------------------------------------- ---------- - ----------------(Title)---- -- --------- - --------------------------------- (Plot plan, showing size of lot, location of system in relation f4ell,, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -,- ------ - DATE -- -------------------------------------- REVIEWED BY_- - - ----------------------------- ------ DATE------ BUILDING PERMIT ISSUED -------------------------------- ------------------------------ DATE------------- Alterations and/or recommendations:---------------------- -- --- ----------- -- -------------------------------------------------------------- ---- -------------------------------------- ------------ ------------------ ----------------------------------- ..............)---4-- --- ----- ------------ Ir ----------- - ----- -------------------------------- ---- -- --- ------------- ------ ------------------------------- --------------------------------------------------�_--------------------------------------- --------------------------------- ----------------------------- --------------------------1---------- ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- Dafe-- ------ -----------------------:------- ---- ---- FINAL INSPECTION BY:. - ------- 7 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Reviseci 1-57 FRCO,�.