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APPLICATION FOR SANITATION PERMIT n Permi# No. __ _. --------- (Complete S._Z(Complete in Duplicate) Date Issued ---- Application is hereby made to the San Joaquin'Loca! HealthlDist ct or permit to construct and#install the work herein described This application is made in compliance witb Cunt Ordinance 549 JOB ADDRESS AND ATI ---------I---------------17------- - - --------------------- ---------------------------------- Owner's Nam --------- ---------------------- - -- --------------------------------- Phone- �1/- � �7 d Address s 'Q -- ----------- ------------------------------------------------------------------------ ----------- - --•• ---- - ------- 7 Contractor's Name------------------------ --` ----- --------------------------------------------- -•------------- Phone-- - ----4_.._14 Installation will serve: Residence Apartmen# House ❑ Commercial ❑ Trail Court ❑ Motel ❑ Other ❑ Number of living units: ____ __ Number of bedrooms _-_____ Number of baths ___tot size ./-5 __ $ w ____________________ Water Supply: Public system ❑ Community system ❑ Privat�y`Loam Depth to Water Table+,? tt. Character of soil to a depth of.3 feet: Sand E] Gravel ❑ San ❑ 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 s-wer is available within 200 feet.) ♦ / / ". Septic Tank: Distance from nearest well----------Distance from fa dation_f-Q-_____--__.Maferial-� -___. -.__--__. No. of compartments-----�------Ft Size---- _ ------Liquid de♦pth---_- _}"i—---------Capacity. - - ------- Disposal __.___Dis osal Field: Distance from neare well ____-- _Distance from foundation__ _ - ,� -- Distance to nearest lot li e____�____. Number of lines_________________ _____ Length of each line--_,7�_--7,`- -- Width of trench----?_ ____.____-_---.--.._-- Type of filter material �!,�1Depth of filter material-----ISrF_____-Total length---/+5-0-_._'---------------------- Seeps e Pit' Distance to nearestAjell/-____-___:___Distance om f undation_ _....___.Distan to nearest lot line_______________ Oh Number of pits.___-vS.,___._-----Lining material_ -__.Size: Diameter-_- - Deptn--.. `# ----------------- Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material_._.____.____- ' - ---------------------- ❑ Size: Diameter------------------ -------------------Depth-----------------R--•-------------------------------Liquid Capacity---------------------- gals. . Privy: Distance from nearest well---.-.---------------------------- --------------Distance from nearest building---------------------------------.-------- ❑ Distance to nearest lot line---------------- ------ - - I Remodelingand/or repairing (describe):------------------------------------------------------ --------•--------------•-----------------•-------------------------------------------------------- -------------------•---------------•-------------=--------- ----------------------------•-----------------------------=-------------------------------------------=--------------------------------------------------- -----------------------------------------------------------------------------------•---- -----•---------------------------------------------------------------------------------•-------------------- 1 hereb ertify that 16 prepared this application and that the work will be done in accordance with San Joaquin County ordinances, t e lawu a r le and regul ions of the. Joaquin Local Health District. )Si ned - - -------- --- --------------------- ------------------ -�_.__ wner and/or Contractor)- 9 }---- ---- -- ------ -- --- --- ---- ---- -----BY= / � ��! ----•-------------- Title) � -------•---------------------da_.i_'"' (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc., can be placed on reverse side). r 1 FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY----------------- ---------------------------------------------------------- DATE--------------- ------ REVIEWEDBY----------- --:------------------------------------- --------------------------------------------------------------------- DATE------'-------- -- BUILDING PERMIT ISSUED---------- =_ - ------ DATE-------------- -------------------------------- Alterationsand/or recommendations-- -------------- ---------------------------------••-------------------------------- - -- --------------------- ------------- ------------------- --------------- ------------------ --- � 5 ----- -• a -- ------ I oJ� _1' ---10 __ _� a. r ` - � . �, " ----------------- -------------------------------- -------------- ------ ----------------------------------------------------------------------- ! FINAL INSPECTION BY::------ -"-------------------------------- Date J:-Q-� j °-'' ( E 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 E5-9-2M . Revised 1.57 F-P.CO.