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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �� Date Issued -_--... ---60 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 D LOCATION ---- -------- -- Owner's Name---- A--------- --- ------- ---------- ---------------------------------- Phone----------------------- -----•---- 01 Address �� ' --- Contractor's Name--------- - ----- ---- ---------- --------- --------------- Phone................................... will serve: Residen Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of livingunits: �__.__ Number of bedrooms .___ R D6 Number of baths -_--�-- Lot size�S�.--�_-.--------,1----------------------------- Water Supply: Public system ❑ Community system V Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay] Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ NoX New Construction: Yes W No ❑ FHA/VA: Yes ❑ Nox TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public a er is available within 200 feet.) Septic Tank: Distance from nearest well-- ------- ___ 1 ani /f�ryom oundation____-to-.__-_-.Mat ri I__--.-4.d�►t� m-t-.�-____-.. No. of compartments_._ _-- ---- ---- izeLiquid depth Capacity... " = Disposal Field: Distance from near well------- .__ ante from foundation-----Y_D__......D,,ii�tance to nearest lot line_...=1__._..... Number of lines_____ -__-__-__--_ Length of each line--- _.�d?h of trench-_--_z �< _ - ..._.-_. .____... Type of filter material--,_________________ Depth of filter material------I.S_______.__Total length......1_4__ ------------------ Seepage _-_A_.-_.__-____-_. q Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- El Number of pits______________________Lining material-----------------------Size: Diameter------------------------Dept h___________-___-___.-__-__.______ Cesspool: Distance from nearest well----------------- from foundation--------------______Lining material------------------------.__-_____-_-_. ❑ Size: Diameter--------------------- -------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------_____.-______-____--______--___._. c` ❑ Distance to nearest lot line--------•------------------------------------------------------------- v Remodelingand/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, Stat laws, a r�areguians of the San Joaquin Local Health DistrictSi ned( 9 )----- - -- -- --- --- -- -----------------------------------------------------------------------------------(Owner and/or Contractor) BY� -- --- - --- -- --- ----------------------------------------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing siz of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------------------- --------- -- ------- DATE------------------------------------------------------------ REVIEWEDBY--------------------------------------------------------------------------- -- -- -- ------ DATE--------$ '- ------- ----------- BUILDING PERMIT ISSUED-------------------- Alterations and/or recommendations-----------------------------------------------------------------------------------------------------------------------------------------------_----- ---------------- -----------------------------------------------------------------------------------------------------------------------------••---------•--------••--------------•------•----------------------------- ---------------------------------•--------------------------------------------------------------------------- --......--------------------------------------------------------------•----------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------••--------------------------------------------------------------------- --------------- --------------------------- ------------------------------------------------------•-------------------------------------------------------ry-----------------�---.-------------------------------------------- FINAL INSPECTION BY--------------- =-------- Date----------f-� Z 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 . Revised 1-57 F.P.CO.