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APPLICATION FOR SANITATION PERMIT Permit No. .l (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ... Application is hereby made to the San Joaquin Local Health District for a permit to cons tcu arra install the work herein described. This application is made.in compliance with County Ordinance No. 549, JOB ADDRESS AND LOC 00 ---------- (� ( .- /dC�—is Owner's Name___Z _ Phone -----------------•--------------------------------------------------------------- Address------------ ------ ------------, 1h __ Contractor's Name �:------•----------------• -------------------------- Phone-------------- Installation will serve: Residence III Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size _ ______________________._ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ •Sandy Loam ❑ Clay Loam ❑' Clay,❑ Adobe❑ Hardpan ❑ R Previous Application Made: Yes ❑I No ❑ 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_________________Distance from foundation--------------------Material____ -__. L, ❑ No. of compartments-------------------- -----Size-----------------------------___Liquid depth -------------------------Capacity-------------- -------- f h Disposal Field: Distance from nearest well--�r6.....Distance from foundation__&_0`___._..Distance to nearest lot 1ine__4 .,______ Number of lines' 1. �r ength of each line----�_Q'_--_________-_`.Width of trench___1-_ Type of filter material _�1__ Depth of filter material----- ---------'Total length----1- -l----=------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------:__.Distance to nearest lot line----_______.__.__ ❑ Number of pits--!-------------------Lining material-----------------------Size: Diameter----------------------Depth---------.----------------------- 1: Cesspool: Distance from nearest well-----------------Distance from foundation_____._-------------Lining material----------------_-___------------------ ❑ Size: Diameter--- ---------------------------------Depth--------------------------------- ------------------Liquid Capacity--------------- -----------gals. Privy: Distance from nearest welL_.__._i.;_._--------------------------------.-Distance from nearest building ❑ Distance to nearest lot line-----------_____r_______.___________--------------------------------------------------------------------------------------------------------- Remodeling and/or repairing --------------------------------------------------- ---------------------------------•----------------------i•--------------------------------------------------------------------------------------- ------------------------------------------------------------- ------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, JState laws, and rules and regulations of the San Joaquin Local Health District. (Signed) � --- }/ ---------------------I------------------------------------------(Owner and/or Contractor) BY- .---------------------------I----------------- ------- ----------------------------------------------------_- --•---------------- _ - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY oe APPLICATION ACCEPTED BY- -fl REVIEWED BY __ � ---- ----------------- - -------------------- ---------------------------------------------------------- DATE - ---------------------------- UILDINGPERMIT ISSUED-------------- '------------------------------------------------------------------------------------- DATE.......................... -- ------------------------ Alterations and/or recommendations:`_________________________-__--------_--_---_-----_-_- __-__--------___- -•----------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- ---------------------------------------- } --------------------------------------- ------------- ------------------------------------------------------------------------------------- FINAL INSPECTION BY:. --- - - ------------------------ Date---/-&___ - I SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 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 8-'54 F.P.Co. 1