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APPLICATION FOR SANITATION PERMITPermit No. -J_ ------�-_---- __-.d (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. JOB ADDRESS AND LOCATION_ -_---------------------------------- Owner's Name--- -------------------•------ -- --Phone------------------------------------ Address -----=---------------•---- Address--------- ------------ '_---------------------'------------------------------------- ----------------- --------------------------------------------- xI 0 Phone --- -------- --------------------------------Contractor's Name Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [I Other ❑ Number of living units: ______ Number of bedrooms ____t Number of baths -1 ----- Lot size --- 4 -47' --Up____________________________________ Water Supply: Public system ❑ Community system ❑ Private W Depth to Water TableS7V--- 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 ❑ No ❑ FHA/VA.. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well __J'0 ------- Distance from foundation ------ #------ __.Material --------------- __________________________________ No. of compartments ------- _---------------- ---Liquid depth ---- S�Vy----------_----Capacity-_4?------------ Disposal Field: Distance from nearest well -@_Q --------- Distance from foundation__/Ct------- ._"_.Distance to nearest l,o``t line ___��_____-._ Number of lines __1 ------------ ----- Length of each line___6j9 ---------------- ---- Width of trench__1T--------------- ---------- yp--.______ Depth of filter material_JIe'________-___ Total length__,�________________________________ T e of filter material_ Seepage Pit: Distance to nearest well --- ------------------Distance from foundation -------- .----------- Distance to nearest lot line ____--------_____ ❑ Number of pits ---------------------- Lining material ----------------------- Size: Diameter ------------------ ----- Depth ------.-------------------------- A 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, line ----------------------------------------------- ---------------------------------------------------------------------------------------------- 9. ------------------------------------------------------------- - s Remodeling 'and/or repairing describe)___________________ -----------------------------------------------•-----------------------•-----=-----•------------------------------------------------------------------- ------------------------------------------------------------------ ---------------------------------------------------'---•-----•-----=------.__......---.--.-•-------------•-------------------...----------------------•---------------------------------------------------------------------- 1 I hereby certify that I have Iiprepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws an rules end re Iations of the San Joaquin Local Health District. (Signed) ----may -- - -- - ------ -- -------------------------------------------------------------------------- (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). a FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY- - �------------------------------------------------------------- DAT E1®'.Z.fl-'rf------------------------------------ REVIEWEDBY---- --------'------------------------------- ----------------------------------------------------------------------------- DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED -------------------------------------------------------------- ----------------------------------------- DATE ------------------------------------------------------------- Alterationsand/or recommendations:--------------------------------------- ----------------------------------------------------•----------•--------- -------------------------------------------- I i ----- Date / —j—,P FINAL INSPECTION $Y:__ -- - - ---------------------------------------------- I 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 , Reviseo 1-57 FRCO,