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•Q APPLICATION FOR SANITATION PERMIT Permit No. ................ (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. JOB ADDRESS AND C ION9 ---�7___j�- ------------------------------------ Owner's Name - ---- - - Phone------------------------------------ Address / ------ --- - ------------ -•------------------------------------------.-...-------------- ••----•---- Contractor's Name-------- "r --- ------ - Phone----------------------------------- Installation will serve: Residence 9�__Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -----.-- Number of bedrooms -------- Number of baths -------- Lot size ____________________________________________________________ Water Supply: Public system ❑ 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 ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • ank: Distance from nearest well______ _______Distance from foundation____________-___--.Material----__-_-_______---_..________-_________________- No. of compartments--------------------------Size------•-----------------•-------Liquid depth--------------------------Capacity------------------0ep isp I R Id: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line__________-_____. Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length--------------------------------- ...... Seepage t: Distance to nearest well--'' _____Distance f om fo�un�dation , ___._01;staw to nearest I°ot li e__f___er-__ Number of pits----j--------------Lining materia �64ize: Diameter_.J _-----___Depth---1-�____-_____._____- Cesspool: Distance from nearest well________________Distance from foundation-.-.------________-Lining material------------------------------------- k ❑ Size: Diameter--------------------------------------Depth------------------------------------------- --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_ -------------------------------------Distance from nearest building------------------------------------------ C ❑ Distance to nearest lot line---------- --------------- ------ - ------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe):---------------------- -------------- ------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------------------------------------- t --------------------------------------------------------------------=------••---------------------------------------------------------------------------•--------------------------------------------------------------- --- -------------------------------------------I---- ----------------------------------------- ------- ------------------------------------------------------------------------ -----------------------------------------------------------•- ------------------------------------ y I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin Count Y p P pP q Y ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. .,. [Signed)-------------- - -- -- "•'- [O 'c►FContractor) pfrion -- ------------ BY=-----------------------_--------- ' (Title) -(Plot plan, showing size of lot, l system in relation to wells, buildings, etc., can be placed on reverse ide). r :, FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------------------------------- ---------------•------------------------ DATE-------------- ------ -----••-----------------. `\ REVIEWED BY--------------•----------------------------- ---------- -- ----- �---------------------------------------- DATE--j-?.r.- ---- --------------------------• BUILDINGPERMIT ISSUED-------------------------------------- � _ DATE-------------------------------------------------------------- Alterations and/or recommendations--------------------- -----------.- --- ------ ----- ----------------------------- - --- - --------------- •----------------------•--------------------------------•---------------------------------------------------•--------• -----------v -- - --- ----------------------------- - ------ ------------_ -----------•-------- -------------------•------------------- -----------------------------•------ -----------------------------------------•----------------------------------- ----------------------------------------- - I --------•-------------------------------------------------------------•-------------------------------------•- •-- FINAL INSPECTION BY:- .: Date/ .--f-`� � ------------------------------------------ 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. Jf