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APPLICATION FOR SANITATION PERMIT Permit No. ____(-.- ------------ (Complete __Z(Complete in Duplicate) It 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. CG JOB ADDRESS AND AT N__-____" -/"__l --- --- ----'z`�`^G- Owner's Name P _ _ Ph - -------- .----�-- .. one-=---•------- ----------------••-•- Address_. � �' (� _._ Contractor's Name______ _ _._ �- a ---- - - r --------------- Phone. ` _ l--- Installation will serve: Residence ❑ Apartment Housi El ",Commer'yal [F��reile�r ,C�o��t ❑ Motei El Other E]Number of living units: ________ Number of bedrooms -----'-. Number ofvlaaths of size f _ Water#Supply: Public system E] Community system E] Private h to Water Table/ f Character'of soil to a depth of 3 feet: Sand ❑ Gravel ❑—Say°Loam ❑--Cl'ay Loam ❑ Clay [-] Adobe ' Hardpan F]Previous Application Made: Yes No eNc( 'FHA/VA: Yes ❑ No ❑ r ❑ New Construction:fYes TYPE OF INSTALLATION AND SPECIFICATIONS: - `I (No septic tank or'cesspool permitted if public sewei is available within 200 feet.) Tank: Distance from nearest well___-_-__-- r-,-I}istance from foundation__________ __ ___. Material------------------------------ -----. No. of compartments Size ---------------------------Liquid depth------------------------.-Capacity----------------------- po field: Distance from nearest well__-."""___ Dista ce Ifrom foundation-----------------___Distance to nearest lot line_______________.. Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------- Type of filter material____ �_______-__Depth ofa filter material_______________________Total length_______-_________._ ` fi ------------------------------------------ 4 It , Seepage/Pit o- Distance to nearest wellla -----------Dista or`n undation___--- -- --------- to nearest loft line- UK Number of pits.__________________Lining material__ �+_Size: Diameter__.�� , De to Cesspool: r - ------------------- ----------------- ___---___-__--_Distance=from foundation-------------------_Lining material------------------------- Distance ❑ ---------------=-------- Size: Diameter Depth ------Liquid Capacity----------------------------gals. Privy- Distance from nearest well______________________ I---------------- Distance from nearest buifdin ti ❑ Distance to nearest lot line--------- .__-______ ___________----- -- ----------------------------------------- Remodeling and/or repairing (describe):____-__. . _ P�lt�_� t ' . ^ -c----------------------- ---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- --------------------------------------------------------------•---------------- --------------•----------------------------------------- -- -- I hereb ice tify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, f to laws, and rut�saA�d� gula+�ionsolf the San Joaquin Local Health District. [Signed) . ---- _ _________ "~ __ ___ _.(Owner and/or Contractor) u ( } – ______________________ __ By%—---------------------- - ,� r ��-----�� - - - Tale (Plat plan, showing size of lot, location'of sys+em ' elation to wells buildings, efc., can be placed on reverse side). x OR DEPARTMENT USE ONLY ; APPLICATION ACCEPTED BY- ------------ DATE_--- ------------------------------------------------------ REVIEWED BY --------------- _ DATE__ UILDING PERMIT ISSUED-------------------.--�---.-.-�--------_-- ---- oQ------- ---- --'--------------- -----------------------------------------~"'-` � – - DATE- Alterations and/or recommendations-— -- ----------------- •---------------- --------•----------- -------•--------------------------------------- __ _ __ ----------------•------------ --"a" -_�. -- . ; ----------- FINAL INSPECTION BY:---------------------f�_-- Date----------- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street r Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1.57 F.RCQ.