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APPLICATION FOR SANITATION PERMIT Permit No. __-_-_ f (Complete in Duplicate) bate Issued ..__j ,_4-s/� 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, ' f JOB ADDRESS AN LOCATION_____V_/�__- 1 4 ��-• -T... ��11 It---D - -f�l _-_..Tp_-/, Owner's Name_- -----••---------------------------- ------------ ------ ------------------ Phone------------------------------------ Address { -� � --- / '•------------------------ Contractor s Name- _ ----------------- Phone-------_______.____________ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: Y____ Number of bedrooms _, Number of baths _Z--- Lot size ____--_ -------------- Water Supply: Public-system CS mmuriity system ❑ Private ❑ Depth to Water Tabled- ft- Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobejLL Hardpan ❑, �s Previous Application Made: Yes ❑ No 0� New Construction: Yes JNo ❑ FHA/VA: Yes ❑ No 11-Z, TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ) t Septic Tank: r ce from nearest well_________________Distance from fou ndation__:-----------------Material------------------------------------------------- Elo. compartments --------------------------Size-------------------------------Liquid dei? h-- -----------------------Capacity---•----•-------------- Disposal Field: foist ce from nearest well -- ----------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ of lines--i-------------------------------Length of each line---------------------.-------Width of trench-----------------------•------- •- z Ty of filter material--------------------- ___Depth of filter material-_____________________Total length------------------------------------------ t Seepage Pit: Distance to nearest I _Di wall- stance from foundation---�..f__-,Distance to nearest lot line__. _ Number of pits---- Lining material___G?o Size: Diameter__,!5?_3_f"__.Depth____ _.______ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ElSize: Diameter------I-".------------------ --,--.-Depth--------------------------- -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ______ -------_---------------------------------Distance from nearest building---------------------------------._______- Distance to nearest lot line------- - -------------- - ---------- ------ -------------------------------- ------- --------- -- 1 Remodeling and --------------------- /or repairing (describe):---------------------------------------------------- 1 -•------------------------------------------------------------• -----------------------•-------------------------------•-------- f I hereby cert' at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a la and rules and regulations of the San Joaquin Local Health District. (Signe -- - ----- ---- --- ----- --- -----------------------------------(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 APPLICATION ACCEPTED BY -- i-------- DATE REVIEWEDBY---------------------------------------`------------- --- --- - ------ DATE----------- --------------•---------------------- BUILDING PERMIT ISSUED--- - -------------------------- ----- ---- -•------- DATE- ---------- • -- -------=------------------- - -- - ---------------- Alterations and/or recommendations:-':---------------------- -- - --------------------------------------------------------------- -------•----.- `----------- --------------------- -------------------------------------------- - - ,/ -------------- ------•--- �'-.5 r -- ---------------------- ------------------- - ------------------------------------------------------- FINAL INSPECTION BY:---- -- --------------------=--=---•-----=-==----- Date---- r �� - 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_ 0-