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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 ------- ------ - - --------tt4.-- ------'les = - ----------- ---------------------------------------------- Owner's Name ------------ y Phone------------------------------------ Address----------------------------------------- f� �/ - ------------------------------------------------- ----- ------------•-------------------------- Contractor's Name r s t�---------------------------------------------•------------------------------------ Phone----------------- ----------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel �❑ Other El Number of living units: -✓-___ Number of bedrooms j____ Number of baths /.._ Lot size -__�_,T�-__•------_------------------------------- Water Supply: Public system E] Community system El Private [�]�pth to W ter Table 7.et. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 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 sewer is available within 200 feet.) /' r Septic Tank: Distance from nearest well__4� 9 scan e rom fou,ration__/O_—?--- Trial__ -__. -----� No. of compartments--------�r'_-_ � _.___Liquid de th__ - ----- _ q p` Capacity--- Disposal Field: Distance from nearest well ____ D stance from foundation ,�x...,,Distance to nearest lot .® Number of lines_- -___- �C__�_ ___ ____-Length of each line_____-__,,__`�2______________ Width of trench..,,`.�.?�..... rr �^ -------- Type of filter material-_ _-__J'�__Depth of filter material-__/_r ___---_Total length-----/_5-__ _____________________ Seepage 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__.-___-___.---___..____.______.___.- ❑ Size: Diameter------------------------ ------- ---Depth--------------------------------•-------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well __________________________Distance from nearest building-------------------._-____________.._____- ❑ Distance to nearest lot lire------ ------------------------------------------------------... Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ----------------••--------------------------------------------------=.• --------------•-----------------------------.------------•--------------------.,--=------------------------------•---------------•--•------•--------- ----------------------------------- -------------------------•---------------------------------•----------------------•--------•-------------------------------------------------------•----------------------------------- I hereby certify that I have pr d this application and that the work will be done in accordance with San Joaquin County ordinances, State awed rule d re ul ions of the San Joaquin Local Health District. (Signed)------. -- ---' ---------------------------- - - --- ----------------- ------------------------------------------------------------------(Owner and/or Contractor) gY :• (Ti#Ie)------------------------- •- -------- =- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FO.R,DEPARTMENT US ONLY APPLICATION ACCEPTED BY____._ ------------ - DATE ------------------ REVIEWEDBY -------------------------------------------------------------------------------------------- DATE-----...---•-----------------------------------...-- BUILDING PERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE------------ Alterations and/or recommendations:---------------------------------------------------------------------------------- ------------------------------------------------ ------------------•--- -----------------------------•---•--------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------...------------ ------------------------------ ----------------------------•----------------------------------------------------------------------------------------- ---------------------------------------------------------•---•-------- FINAL INSPECTION BY--------------- -.----------------- Date-------- /-.1-_JS 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 ES-9-2M , Revisea 1-57 VP.Co.