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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. V JOB ADDRESS AND LOCATION. �� -�-- ------ --- -------.•gc -•--------- -• Owner's Name----------------- `-G------- C--` j� _+ z —---------------------- Phone--------- -- ---------- . ----------- - -f---- ---- '----jr---•-•- C�- --aln"-...--------•--------------------------•--- Address4P --------•--- Phone s Name----------- ----- ---•--------------- �•-------------------------• ------------------------ -- ---------------------- ----- -------•----- x p -Motel ❑ Other ❑ f Installation will serve: ` Residence [�A artment House ❑ Commercial ❑ Trailer Court ❑ Pr Number of living units: _.____ Number of bedrooms /'___ Number of baths ---/-. Lot size ___- —----_.__ _---------------------- -- Water Supply: Public.:system ❑ Community system ❑ Private [E-15-epth to W ter Table _______= ft. Character of soil to a!depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam [I Clay ❑ Adobe ❑ Hardpan E] Previous Application Made: Yes ❑ No New Construction: Yes �o ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearesr well6/01�_____-.__Distance fro foundation,ll]_______.___.Material__� -------------------___ __________.. ® No. of compartments-------�. ------- --S,ize__ ,--Liquid depth---- _`-------------Capacity..... . Disposal Field: Distance from nearest welllp _._'7__Distance from founclati n.Z_,�_ __.___.Distance to nearest lot line_�0..... W1 Number of lines------- Length of each line_�0__________________Width of trench.___ 'L�_____-_------______ Type of filter material___#_Depth of filter material_____"__--_-Total length----------- 6 r-------------- Seepage Pit: Distance to nearest well-----_-------_--------Distance from foundation___••._____..-.___.Distance to nearest lot line---------------__ ❑ Number of pits----------------------Lining material--------------.--------Size: Diameter-----------------------Depth---------------.----------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material------------------------------- Depth-------- ------------ --------.--- ----------------Liquid Capacity------------------- gals. El Size: Diameter Privy: Distance from nearest well___________________________ -------------Distance from nearest building---------------------------- - ❑ Distance to nearest lot line------- ---------------------------:-------------------------- -----------------------------------•--------------------------------------- Remodeling ------Remodeling and/or repairing (describe):------------------ ----------------------------------------•-----------------------------------•--------------------------------------------•-••-------- -- ----- -------------------------------------------------------- -----------•---•---------,---------------------------- ------------------------ _... --------------------------------. -------- --------------- - --------- I hereby certify that I have prepared this application and that the work will: be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. -- Ile -------Owner and/or Contractor (Signed) v Title (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse sidel. FO ® ART . NT USE LY APPLICATION ACCEPTED BY---- -- -- - ----R----------- r --------------------- ---- DATE ._.. 1-5 ------------------- REVIEWEDBY------------------------------------------------------- ----------------------- ------------------"-------------------------- DATE------------•-------...------------------------------------- BUILDINGPERMIT ISSUED---------- ------------------------------------------------------------------------------------------ DATE.---- ----------------------------------•------------------- Alterations and/or recommendations---------------- -------------------------------------------• -------------------------•-------•--------•--------•--•--•--------------------------•----------- --------------------------------------------------•---------------------------------------------------------------------------------------- ;------------ --------------------------- ------------------•-----•--•-------------------------------------------------- 4- _ ______________________________________________________________________________________________________________________ i __ ______ � _ _____________________________________ FINAL INSPECTION 13Y:...-------, - ----- 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 i ES---9-2M Revises 1.57 F.P-M