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APPLICATION FOR SANITATION PERMIT Permit No.H..1._._, (Complete in Duplicate) Date Issued .*-�— _ Appli-ation 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. ' aJOB ADDRESS AND LOCA cs _ �r ----- --------------------- Owner's Name__ -��---------...� � '--•----------------------------- -------------------- ----------- Phone------------------- -------..-------- Address.... =---------- ----------------------- ---- wf ---------- .._..... -- - Contractor's Name------------- , Phone---•------------------------------- Installation will serve: Residence 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 Loam2❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [lNew Construction: Yes ❑ No FHA/VA: Yes ❑ No e TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ptic nk: Distance from nearest well_________________Distance from foundation---------------------.Materia!-----------------------____-_.-.___-.._____•__._: No. of compartments--------------------------Size-------•--------------------=---Liquid depth--------------------------Capacity----------- -- Dis sal ieid: Distance from nearest well-----------______Distance from foundation_____.-_______--.-.Distance to nearest lot line_____.- i Number of lines---------- -Length of each line Width of trench--- Type offilter material------------ Depth of filter material--------- -_-AA-_-------Total length--------------------------- --------r•-- Seepage Pit: Distance to nearest well_.___" --- Distance tom fo dation__:�,111_._____.Distance to nearest lot line__��___._- number of ts___ ____________ ____Lining material / �/.5ize: Diamete ��_...___De th___ e--________-_--- p' 1 / r- ---- Cesspool: Distance from, nearest well-------------:_Distance from foundation_____,_,__..'°------Lining material--------.'___________________________. kEl SiDiamete ----- -------------------------------Depth---------------- ---- ------------------ ---------Liquid Capacity-------'--------------------gals. ! 1 ------------------------- Privy: .Distance fr�omi•nearest-well:_,_'" '= - --_ _________ _Distance from nearest building_ - _.______Distance to nearest lot line_______________________ ------ ---- - --------- •7--------------------------- - ---- Remodeling and/or repairing (describe):---------"------ - ------------------------------------ -------------------- -----------------------==-------------•-------------- ---------•---------•---------------------•-.------------ -• :I -t------------------------------------------------- I j -------------------------------------------t - - ---- -------- ----------------- -------------------------------------•-------_-- 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 es and regulations of the San Joaquin Local Health District. _- _,� mor Contractor) Si ned •---------- ( g -- - -- , --------------------------------(Title] '� - - ---------- (Plot plan, showing size of lot, loc i of system in "relation to wells, buildings, etc., can be placed on reverse id ). FOR DEPARTMENT USE ONLY .. ---- DATE----_-------------- ------- APPLICATION ACCEPTED BY.-:--------- ---------------- --------------- -------------------- ------------ REVIEWED BY------------------------ -7---- DATEJZA_ --------•--•----••--•---_-------------------- _ �t -- - b BUILDINGPERMIT ISSUED-----------�---'--- ---- ------- -------- �-- ----;=`-------=�----------------------- ------- DATE-----'Qr't-------------------------------- --------------- J, n J Alterations and/or a mend orf ,_-- �, -- - ------------ --------------------------- ____ --- --------------------------------------------= --------------------------------------------------------------------------------- ----- - ----------------- ;--------- :. - ------------------ ------- ------------ -------------------- --- ---------------------- FINAL INSPECTION BY.._ ----- - Date__� _t-.�� __ .. ----------------------------------------------- SAN JOAQUIN LOCAL HEALTHDISTRICT � k ' _. 130 South American Street 300 West Oak Street 132 Syce ore Street{ � r ;___`814 North"G" Street Stockton. California Lodi, California Manteca, California Tracy, California i 4 LS-9--2M . Revised 1-57 F.P.CO.