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APPLICATION FOR SANITATION PERMIT Permit No. ..... z --__-- (Complete in Duplicate) . 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. r JOB ADDRESS ,A D ,LOATION_r - - - `--- ----- - J Owner's Na�Jme -= -------- ---'-----"�f1----- ------------------------- ------- Phone---------------- —-------•----- Address "�� -- Contractor's Name---------------------------------------------------------------------------------------------- ---------------------------------- Phone_..------. --------•--------------- Installation will serve: ' Residence F] Apartment House ❑ Commercial E] Trailer Court [t M tel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size _____________________________________________________ ____ Water Supply: Public system ❑ Community system ❑ Private �pth to Water Table --------- ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam - Clay Loam E] Clay E] Adobe �ardpan ❑ Previous Application Made: Yes ❑ No 'New Construction: Yes Loam ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewerAs available within 200 feet.) r Septic ank: Distance from nearest well_� ____l?istance from �unda �on___ Mater Ir No. of compartments_____---_ f`__-�__SizE_�_ .Xs __ _y_�_Liquid depth__________ ___________CapacitY___�__ _'3 _T}__ bis os Field: Distance from nearest w it 11_Q_____Distance from foundation-- __�_ ______Distance to nearest lot lin p Number of lines----------- _ Length of each line_____.-_____ --0---- Width of trench________�ry______ ___ Type of filter materi ,__ ( " Depth of filter material------- _ --------Total length___________�_.15c __..__.-.-_.__-- page Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line.__--_._.__-.._.. Cf1 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation____----------------Lining material__-_____----_______-_.__-______ m ❑ Size: Diameter------------------ ------ --------- Depth--------------------- -----------------------------Liquid Capacity----------------------------gal Privy: Distance from nearest well-__.4 ------------------------------------------Distance from nearest building________________________________________ ❑ Distance to nearest lot line---I---- I ----------------------------------------------------------------------------------------------------- Remoin /bc ---------------.--- -n - - -( 4--• '------------------------------------ -------------------------------------------------------------------------------------------------------------- ----------- -------------------------------------------------------------------------------------------------- I hereby certify that 1 have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. C 0 ,�,�5 ` 1 {Signed) - --'--�'-`--------w- -"0'{ ,- h-�` ------ --------------------------------------------- {Owner and/or Contractor) ---------------------------------------------- By------------------------------------------------------------------------------------------------------------------------------------(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 APPLICATIONACCEPTED B ----------------------------------------------------------------------------- ----------- DATEd---•--•------ -------------------------------------- REVII;WED BY ----- ------------------------------------ DATE--- ------------ BUILDING PERMIT ISSUED - DATE. �-------------------- Alterations and/or recommendations__________________________ ------------------------------------ -------------------------------------------------------------- --------------------------------------•-----•-----------------------------•------------•------------------------------- ---------------•---•-------•- -----------------` --------------- - ---- ------------------------•----------------•--------------------..-..------------------- ------------------------- --•------------------ 1)FINAL INSPECTION BY:.._ -----------4 --------------- 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-9-2M Revised 1.57 F.P.Co-