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APPLICATION FOR SANITATION PERMIT Permit No. ..... (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. 1 101, r JOB ADDRESS AND LOCATION� = t` lc - .� r '-- 1 6. 1{'_..':x., Owner's Name --All ! � {_- �/- _-�--/------------------- ----------._. Phone Address " ..' r - --- --- ----�--------- Contractor's Name------------------- --- - -------- ----------•-----------------•------------------------ -------------------------------------•-------- Phone------------------ ------------- Installation will serve: Residence ,;R A artment House ❑ Commercial ❑ Trailer Court ❑ Mfote! ❑ Other ❑ Number of living __ units: -- _ Number of bedrooms _ Number of baths ____ Lot size ________ _ '. -- ...v_._-.----------- Water Supply. Public system ❑ Community system ❑ Private& Depth to Water Table, (- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No l 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.) Septic/Tank: Distance from nearest well-- - �J Distance fro founda on__.__f-._ _.Material--______- ------------ ------ No. of compartments--------— ---------Size_ ,..x. - Liquid depth___ "___._.___-Capacity---. --en-_0 Dis o el Field: Distance from nearest well----600 ?,,._�_Distance from foundation----; A!�_.Distance to nearest lot line Number of lines-------------!----____------.-_ Length of each line----- _�_,_t.Wic16 of french.......... ;_ ------------ Type of filter material__�a �--- epth of filter material__._. ___--_--_Total length----------- _C..?--__-_-___.___. Seepage Pit: Distance to nearest well___-_-__________-_Distance from foundation-------------------.Distance to nearest lot line----------------- 11 Number of pits----------------------Lining material--------------.--------Size: Diameter---------.-----.--.----Depth-------------------------------.- Cesspool: Distance f-om.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---------- ---- ------------- ------------------------------------ ---------------------------------------------------------------------- Remodeling and/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, State laws, and rules and(regulations of the San Joaquin Local Health District. (Signed)----- �`--1 -----`------------------------------------------------------------------ ------- ----- ( / ___.___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 APPLICATIONACCEPTED BY-------------- ------------------------------------------ ---------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------ = =------------------------ DATE----- � REVIEWED BY--------------------------------------------------- ------ DAT -------5. - -- Alterations and/or recommendations: - --------E --------------------------- -----------------------------------------------------------------•--------------------------------•-------------------------------- -----------------•------------------------------------------------------•----------- -----------------------------------------------------------------------------------------------------------------------------•---•---------------------------•--------------------------------------------------------------- -------------------------------------------------------------------------- --------- ----- --------------- ------------ ----------------------------------------------------- ------------------ FINAL INSPECTION BY_________________________ ' - Date -- -------------------------------------- ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Woof 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9--2M - Ravisaa 1-57 F.P.CO.