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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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. : . JOBADDRESS AND CATI N-----��,�---- - - - - ------------------------------------------------- ------- ------------------------------------- ------ Owner's Name " sZe{l•�u-------------------------------------------------------- ----------------------- ---- ---- Phone-------------------------------•--- � Address- ------------- - • -------------------------------------------•--•---------------------------------------•----------------------------•------- Contractor's `Name -------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms A Number of baths _/___ Lot size _ ------------------------------------- Water ---------------------------------Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet Sand [jGravel E] Sandy Loam ❑ Clay Loam [) Clay F] Adobe Hardpan C3Previous Application Made: Yes E] !No New Construction: Yes ❑ No [ FHA/VA: Yes ❑ No ®— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool per'mitted if public sewer is available within 200 feet.) p�ic ank: Distance from, nearest well------- Distance from foundation______________ ____.Material---------__-______._-_ --_______.__.____.._____._. No. of compartments -------------- __Size--------------------------------Liquid depth--------------------------Capacity-------------------- - Distance from foundation tW_i__------Distance to nearest lot line--------_________isp I Fi d: Distance from nearest wel_J!9__� Number of lines--------. -- -- --- ------ ength of each line-----�e' ..............Width of trench------ --------------- f { Type of filter material__ _ eph of filter material------/f--_______Total length________ -- a Pit: Distance to nearest well__ __�_Distanca from undation___2�_�_-.Di tante to nearest lot line_--4AW-/ Seep Seepage Number of pits_____ _____________Lining material__-_.Size: Diameter-_-_-Y,,Z `--'____Depth_____._-i--____________________ Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material-------------------------------------- C1 ❑ Size: Diameter---------------------------- - -------Depth--------------------- -----------------------------Liquid Capacity- - -------------- ---------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- ��l Sf ❑ Distance to nearest lot line------------------------------- ------------------------------------ ----------------------------------------------------------- Remodeling and repairing (describe): -------------�C ----------------------------------------------------------- ---------------------------------•----------------------------------------=--------------------------------------------------------------- -•------ 1 ------------ -----------------------------------------------------------------------------....------------------------------------------------------------------------------------------------------------------ - 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 r s and regulations f the San Joaquin Local Health District. f _ ____________________{�r Contractor) (Signed) - - - ------------ -- ---------------- -1 --- - ------=----------------------------(Title)------ 7-=�� ----- --- (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ----------------- --- ----------------------- ---------------------------------------- DATE------------------------ ------------------ REVIEWEDBY.------------------------------------ ------ -- ---- -------------------------------------------------------- DATE---------------------- -- ------------------------------ BUILDINGPERMIT ISSUED----------------------------------- -- --- ------------------------•----------------------------- DATE------------A-J--------------------------------------- Alterationsand/or-recommen tions------------------ --------- ------------------------------------------------------jF-------------------------------- ------------------------------------ ---------- - -.. - -- ------------ FINAL INSPECTION BY___ ________ ___ _ ----------------- ---- -------- Date------------ F = -------------------- - - .(�,;�- `'"'� --- - - AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 FY.CO. i � _