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APPLICATION FOR SANITATION PERMIT Permit No. �-� (Complete in Duplicated Date Issued ....... ________0 i This Permit Expires 1 Year From 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 . 549. I JOB ADDRESS AND LOCATION--------3- ----- -------- Owner s Name---- -- - •-- -- -•---•� - --------------------- •---------- -------- Phone------------------------------------ ----------------------- Address---------- Phone----------------------------------- Contractor's Name------- / -------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [3 Motel ❑ Other ❑ Number of bedrooms _ Number of baths __/___ Lot size _ f -----------------------------•-- Number of living units: -� -- Water Supply: Public system ❑ Community system ❑ Private [j--Crpth to Water Table _ _ ft. Character of soil to.a depth of 3 feet: Sand E] Gravel Fl Sandy Loam ❑ Clay Loam El Clay E] Adobe Hardpan [jPrevious 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.} Septic Tank: Distance from nearest welL________' Material a l-------------------------------•----------------- _____bistance from foundation_________________ _. Capacity----------------------- ❑ No. of compartments--------------------------Size-------------------------------Liquid clpth--•--------------- v Disposal Field: Distance from nearest well -.epp-____--Distance from foundation_.,_..__.--.--Distance to nearest lot li y__�______-- �—� Number of lines-- /---------(-----------------Length of each line-------------------- c -------.Width of trenh---- ,--------------------- Type of filter material__--XR __---.--Depth of filter material---- $--._�------Total length___ ___ -----------------•---_/--- � Seepage Pit: Distance to nearest well_lQ 0 -- - -------- from foundation_ ________--_.Distance to nearest lot line-_._ .____ Number of pits-------- ---------------Lining material-- o-� -..Size: Diameter_. ------------Dept h--------.'�-�1-- ---------•--- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-___..______________.___-_________.__ ❑ Size: Diameter-------------------------- - ---.Dep th----------------------------------------------------Liquid Capacity----------------------------gals. i Privy: Distance from nearest wel!--------------------------- - Distance from nearest building.............................-........... ❑ Distance to nearest lot line---------------- - -----------••---'------- i _ ----------- Remodelinand/or repairing (descri,e�:________________r___________---------------------------------•-----------•---------•------------------------------------------------------- ; - I •--------••----------------------------------- ----------- ---------- . ------------------ ---------------------------------------- I hereby certify that i ve repared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a I and regulations of the San Joaquin Local Health District. . - � � _---------------------------__._____.(Owner and/or Contractors l e ------- ------------------------ ------ -- ---------------- By:__ - ------------ ---- -- (Title)--- i (Plot plan, s ow' size of lot, locat' n of system in relation to wells, buildings, etc., can be placed on reverse side). � rt a FOR DEPARTMENT USE ONLY l APPLICATION ACCEPTED BY--------------------- --- -- --- ----- ---------------------------------------------------------------------------------------- DATE-___--- ------------------------------- REVIEWED,BY--------------------------------------------------- DATE_--- - ! -------------- BUILDING PERMIT ISSUED ------•---------------------------------•-------------------------------------------- -------------- DATE--------------------- Alterations and/or recommendation s:__ --------------------- ---•------•------------•------`-------- ------------ --- ---- _-- ----•--- '-'------------------•----------...----------------- -----•--------- ----- ----------- ------------. --- FINAL INSPECTION BY--------------- - ------------------------------ Date---- rN ------------ ----------------------- -------- i SAN JOAQUIN LOCAL HEALTH DISTRICT 132 S camore Street 814 North "C" Street 130 South American Street 300 West Oak Street y Traty, California Stockton, California Lodi, California Manteca, California ES-9-2M Revised 8-'59 F.P.CO. +