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APPLICATION FOR SANITATION PERMIT Permit No. ..... --.-y (Complete in Duplicate) S — 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. T�yf - JOB ADDRESS AND LOCAT N. .' ( ---- ............- - '�!. !C».: . y� Owner's Name--- ---! -.t!--- ---- ----- ----- • ................--- ----------- Phone ......... Address - " . Contractor's.,Name__.. .------------------ ---------------------------------------------------- -•----------•------ ---------- - •--- ........................ _.-._ Phone................................... _ Installation will served licence partment House ❑ Co mercial F1 Trailer Court E] Motel ❑ Other I-] r Number of living units _ -__ Number of bedrooms .._ _. Number of baths ._�... Lot size ..._. . 7?"' J Water Supply;-P.ublic system ❑ Commuqity,systernW Private Depth to Water Table rte_ ft. Character of soil to,a depth of 3 feet: Sand ❑ Gravel • Sandy Loam ❑ Clay Loam 0 Clay Adobe❑ Hardpan ❑ Previous Application''Made: Yes F-1No �r�,,r New Construction: Yes ❑ No FHA A: Yes❑�No TYPE OF INSTALLATION AND SPECIFICATIONS: at . (No septic tank or'cesspool permitted if public sewer is available within 200 feet. Septic To k- Distance from nearest well.....:........:.Distance from foundation._.__..............,.Material............ .I............ .................... No. of compartments:--- ______ ____...Size.........._.....................Liquid depth _._..___ _---Capacity Disposal Field: Distance from nearest well-_ &Aistance from foundation-_.. ._...._-Distance to nearest loth ®... �...., Number of lines. -.___I --. _ Length of each line.------12.._ Width of trench �+: Type of filter matenal_,5_�j�' epth of filter material..... .. -. length._....�I.. .........----_--_---__. eepage 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.. __... __.._ ..`....,_:-_.,. ❑i Size-:'Diameter.-, -•---.Depth--7----------------- ------- .......Liquid Capacity. ..---.....................gals. -, Privy: Distance frorrl'' nearest well-_ ________------------------Distance from nearest building._.;_ ........................ --...... ❑ Distance-to neatest lot line-.--- ------ ---- - •---- ...................................... Remodeling and/or`repairing.(describe):--6"- -ts. + ----------------...................................................................................................-----•------ ------------------------- ----- -- •------- -- ---- ------ ------ --------- ------ -------------•-- ---•-- • -• •--•-- - 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 44fe laws, amd rules and regulations af the Sart Joaquin'Local Health District. (Signed)..- -- '._ ..., ...... --- -------------------------- ------------------(Owner and/or Contractor) By:....-- ----- -------- ------ ------. ------ ------. ........... . ..........................(rifle)......................... . ... ..-- ------ (Plot plan,showing size of lot, location of system in relation to well buildings, etc., can be placed on reverse side)). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. DATE REVIEWED BY --- ------ - --- DATE ......... . ..+� BUILDING PERMIT ISSUED.............•-----------._-_ ---... DATE_ Alterations and/or recommendations.................... .. ..... (-� p .................. ....._ .._.... ----_-- ------- -----•- - ---- ------- -------- --- --- ----------,7 FINAL INSPECTION BY:.- •. ..._. Date =.�-, -� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American,Street 300 West Oak Street 132 Sycamore Street 814•NwA 'V'Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revises 1.57 F,P.CO.