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z- APPLICATION FOR SANITATION PERMIT Permit No_ ________________________ Z ICom ( lete in Duplicate) P 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 - --p--- - --------------------------------------.................................................----------- ------- Owner's Name-------1 -"-"-t------ •-- -t------------------�-------- - -- - -------- --------- ----------------------- Phone------------------------------------ Address- GSi---------- ----------- ---- s ----- Contractor's Name-------- -- -------------------------- Phone-----------•---------•---_- q Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ -j") Number of living units: -1---- Number of bedrooms J--- Number of baths ___f.__ Lot size __�_�_x-_�.�-------------------------� } - Water Supply: Public system El Community system X Private E] 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 ❑ No [K New Construction: Yes A No ❑ FHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Se tic Tank: Distance from nearest well_ __ __ Distan e frQrryfound t' n---- _. ---------Mat rial__ _____________ No. of compartments------'1 __------------Size- /�- //1- ).iquid depth------- ----------------Capacity-- -/OQ..---- Dispo al Field: Distance from nearest well_�_Gr�O_Distance from found ion-___/_0...._._-Distance to nearest lot��ne_.�? Number of lines--------- _ _-_____ Length of each lineAS,= Width of trench---3_(-_ _______._-_____-__ /T Type of filter material____5_��jDepth of filter material___ __-________Total length_____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.________--______________-___________. ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity_--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________________________________________- (,v ❑ Distance to nearest lot line------- -----------------------------------------------------------------------•-----•------------------------------------------------------ Remodeling and/or repair' g (d scribe): %C .. -- -•-------------•••464&- -).., •w • A-d-----•------------------------••-----•---------•--------------------------- ----------•--•------------------------ ................ ------------------------------------------ -------------------------------------------•-------------------------------------------------------------------•-----------•---------------•---•-------.---- - ----------------- 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, and rules and r g tions of the San Joaquin Local Health District. (Signed)` ------------------------------------------------------------------------------------------ ------(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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------------------------------------------------- DATE REVIEWED BY-------------------------------------------------------------------------------------- --------- i��----------------- --------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------- ----- ---- ------------------ DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------- -- --------- - r------------------•----------------------------------------------•------------- ------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------•-------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- FINAL INSPECTIONBY:---------- P1s-0Date------------------------ -r-! ------------------- 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. r