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APPLICATION FOR SANITATION PERMIT Permit No. f--�'- ✓ [Complete in Duplicate) Date Issued -__ /j Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe& pp h County Ordinance No, 549. This application is made SON---- ' � _,444_ JOB ADDRESS AN;_0-jCPf_ Owner's Name----•---- f - - ------ --- -------•------------ ---------- ---- - ----- -------------------------- - .... Phone.____.__ ------------------------- Address ---------------- Ad d ress_-------�,C)1----_�-�/-• -------------------------------------------------------------------•--------------------------------------- --------------- ---------------------- - Contractor's Name--------- ------ Phone-----------------------=-•-------- Installation ----------------------------- Y p- - ❑ Motel Other Installation will serve: Residence A artment House Commercial ❑ Trailer Court ❑ ❑ Number of livingunits: ___ __ Number of bedrooms __V Number of baths ----L Lot Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table .-Q ft. Character of soil to a depth of 3 feett: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe x Hardpan ❑ Previous Application Made: Yes ❑ .-No� New Construction: Yes ❑r No>< FHA/VA: Yes ❑ NoA TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Se tic ja Distance from nearest well-____..,._______Distance from foundation_ ___:__.___"-_._.Material ___________________________ _ ---- s.r _ -- T- No. of compartments------------------------- --Size__.-----•------------- ---- -_Liquid depth---_---- ------ ---- Capauty_-- _ i osal Field: Distance from nearest well--S.0------ from foundation___---/�-___-_-Di�,},ance to nearest lot lin ___ --- Disposal D sp r Number of lines_______-3__________________ _Length of each line_ -------- Type OQ"' ►+� �idth of french----- -----___________-_ I Type of filter material_:��Depth of filter material------ ---Total length-------/- r�--------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation... ...........------Distance to nearest lot line__________._____ t❑ Numberof pits----------------------Lining material-------------=---------Size: Diameter-----------------------Depth__.------------------------------ Cesspool: Distance from nearest well_________________Distance from foundation._.__.___..___.___.Lining material-__________------------ ale. Diameter_ - -_•-------D.epth------•-------------_-- _---------_-----Liquid Capacity----------------------------gDistance from nearest well-___________________-__ Distance from nearest building_____---______________-_--------__-------. ! Privy: ------------- ❑ Distance to n �restline------------ --------------------------t------------------------ _ ----------- Remodeling a ./o repairing [de .--- r-------------------•----------------- •--- - ------------------------------------- --------------------------------------------•-------------------------------- -------------------- ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an ru s andegulations of the San Joaquin Local Health District. x ------------------------ -___.-_______[Owner and/or Contractor) (Signed)--.f- i ned ---•- Tale ---- - - ----- - ------------- (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 r -------- DATE------------------------------------------------------------ DATE.----- REVIEWEDBY----------------------------------------------------------------------- --- --f-- ---- -- DATE BUILDING PERMIT ISSUED-------------------------------------------------- ------- --------------- --------------------- -- ------- ----- - -------------- - --------------------------------------------------------------- Alterations and/or recommendations:-------------- ----- -----------------------------•-----------•---"-- --------------------- ------- -•----------------------------- ---- ----------------------- - - FINAL INSPECTION BY---------- ------ ---- - Date ... - --- + SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street � Stockton, California Lodi, California Manteca, California Tracy. California } ES-9-2M , Revisea 1.57 F.P.CO.