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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 instal[the work herein described. This application is made in compliance with County Ordinance No.a149,JOB ADDRESS OCAT -1Owner's Name-_ __ -_ _CLj-- _ --- �` ' - -------------------------------------------------------- Address----------- - -___ - ----------------------------------------------- ------------- - - ----------- Phone--------------------- •- ------------- -------- Contractor's Name —--------------------------- --- - - --------- ------------- ---------- -- ------------ Phone-----------------------••--------- - - ------------ Installation will serve: Residence Apartment House Or Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_ ---- Number of bedrooms _ Number of bathsLot size ---- S— Water Supply: Public system Community system ❑* Private ❑ Depth to Water Table .S• Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: Yes:❑ No [ New Construction: Yes ❑ No B--_�'FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) .p k:r I Distance from nearest well from foundation--- ------------------Material No. of compartments------------ --------=--- Size--------------------------------Liquid depth-- ----------------------Capacity---------------------- Id: Distance from nearest el- _ --__-_----Distance from foundation___ SDistance to nearest lot line- Number of lines--.-- _- -- Length of each lin _- - - Width of trench__-_ Type off 1#er mater al-- . _Depth of filter mate a_____ �jTotal length----------------srj __ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------:Distance to nearest lot`line_----__-----_ ❑ Number of pits---1------------------Lining material-------------- --------Size: Diameter-----------------------Depth-- ----------------- __-_ - - W Cesspool: Distance from nearesf wefi-----------------Distance from foundation-------------------Lining material------------------------------------- El Size: Diameter----I---------------I-- -------------Depth--------------------------------------- .I - ----------Liquid Capacity----------------------- Privy: -----gals. r t Distance from nearest well_____________________ ___ Distance from nearest building - -------------- g----------------------------------------- I ---------------------------------Distance to nearest lot line--------------_-.-.-___---------------__---___-_ Remodeling and/or repairing (descr6e)____________ ---••--------------------------------- ----------------------------------------------------------------- ----------------•----------------------------------•-------- ------ ------------------------------------- -----------------•----------------------------------------------------------- ---------=---------------------------------- that I have prepared this application and that the work will be- done in accordance with San Joaquin County or mantes, fate s, and rules regulations of the San Joaquin Local Health District. (Signe }.--- - -- -- - -- ----------- C �- � - -- . caner and/or Contractor) BY= Title ---------- ------ --------------------------- ---- ------------------------------- (Plot plan, showin 6size of lot,'location of S min.relation to wells, buildings, etc:, can be placed on reverse side). ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------------- -- ------------ --- - - ------ - - - DATE------------ REVIEWED 8Y- _ - - ------------------------ ------ DATE---- - - -A---- ----------------------------------- UILDING PERMIT ISSUED ------------ DATE-------------------------- - --- ------------------------------------------ Aterations and/or recommendations:_I ------------------------------------------ - --------------------------- ----------•-------- -•----------- --- FINAL INSPECTION BY-,------------_--_ -._ __ ----- ---------------- -------- Date------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American.Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street I -_ Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1.57 F,P.CD.