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APPLICATION FOR SANITATION PERMIT Permit No_ ----------________/.. (Complete in Duplicate) pate Issued ----%f_/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 �-------------------------------------------------------- - ADDRESS AND LOCATION---.---/_---_'''�-.-�-- -__ -- ----------------- ---•- Owner's Name ` � . "j Phone, Owner ---------- Address7-_ '�'`�'�' ------------- -----------------------------•------ ----•-•--------••-------------- ------------- Contractor's Name-----y�.�- ---------------------------•--- Phone Installation will serve: Residence t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: _I_.__ Number of bedrooms ---L__ Number of baths _I-___ Lot size ---- Water Supply: Public system ❑ Community system ❑ Private R� Depth to Water Table Ys- 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 4 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___�Q_____,Distance from foundation_1 _r4________-.Materia---_________-___ .__ No. of compartments------rid---------------Size__D� x_'1.3 0_Liquid depth-----�----------------Capacitytolo- --------- Disp�o�sal Field: Distance from nearest well---GA_1_.----Distance from foundation---0-.---.---.Distance to nearest lot line-------,______•- Number of linesLength of each line_-_4 a~- -------- Width of trench ----------------------- Type of filter material__IY_ .---Depth of filter material_l _______________Total length____ .G_'..-___----_------_.--------•- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- F1 Number of pits----------------------Linirg material-----------------------Size: Diameter-----------------------Depth_-_---.-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------.Lining material-_-____..____._____.___.____-._____- Size: Diameter-------------------------- ----------Depth------------------- ---------------------_ Liquid Capacity----------------------------gals. Privy: Distance from nearest well---_-______----------------------------------- 'Distance from nearest building----------.---------------------.-.------- ❑ Distance to nearest lot lire. - ---- ----- --------------------------•-------------------------------------- Remodeling and/or repairing (describe:----------•--------------------------------------------------------------------------------------•--------------••----•--• - -------------------------- --------- --------------------------------------------=--------------------------------------•--------------------------------- - I hereby certify that I have prepared +his application and that the work will be done in accordance with San Joaquin County f ordinances, State laws, and rules and regulations of +he San Joaquin Local Health District. (Signed) = '!" -------------------------------------Owner and/or Contractor) By. -------- -------- -- - - - --------(Title)- ---------------------------------------------------------- --- ---------- - - ------ ------------------------- - (Plot plan, showi go 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- -------------------- DATE---_a$`'_.L? -'E"7- �--------------------------- - ------------------------------------------- REVIEWEDBY------------------------- - ---- DATE - ---------------------.... BUILDING PERMIT ISSUED------------- -------- ----------------------------------------------------------- ----------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------------------- - ------•--------------------•-----------------------•---•----------------------------------- ------------------------------------- ------------------------- - ----- -- --------- --------------------------------- FINAL INSPECTION BY:----------- ----------------------------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Forth "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1.57 F.P.CO.