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i; All 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. JOB ADDRESS OCATION_ � / �--------- ' " =* ' L -------------------------------- Owner's Name --------------------------------------- -- ----- Phone-----------------•---------------- Address------------- ^,-r'c✓ - - - - - - - - - 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'f Depth to Water Table __ / ft. r ti Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No'F4— 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___________._______________________________- No. of compartments .' Size Liquid depth -------------------------Capacity---------------- Disposal Field: Distance from nearest well ____._Distance from foundation _._.Distance to nearest to#!je- ___________ ` Length of each fine___j _-�___s �_.Width of trench__ x------------------- �__ Tlype of -ilterumber of nmaterial-- __.______.___Depth of filter material_1-4? __________Total length____[- --- 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--_____-.______._______.____________- e, ❑ Size: Diameter------------------------- -----.Depth--------------------------- ------ ---------------.-Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building________________________________.______._. ❑ Distance to nearest lot lire------------------------------------------------------------------------ ---------------------------------------------------------------------- Remodeling and/or repairing (describe) *------------------------------------------------------------•--------•---------------------------------------------------- w � ----------------------- -----------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------ 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 rules and regulations Pf the San Joaquin Local Health District. (Signed).'.;... �------------------. -----------------------------------------------------------------"--------------------------------------------------------(Owner and/or Contractor) By:---------------------- ----------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------__________.._ DATE______. ___-- _ - - - - - - -- - - - Af REVIEWED BY-------------------------------- _ `, DATE--- >• 1 BUILDING PERMIT ISSUED ------------------ ---------- ---- - DATE---------------------------------------- BUILDING and/or recommendations:______. __ • _._--.i�- -- --�-..6-_ ----��±7-,. e1 -----------------+VV =- -- --______ •�a�-- - -- :��.r•.- ----- ---` -- -- ------ -- ------------- ,•�---------_____ -------------------------------------------------------•-----------•----------------- -------- ------------------------------------------------------------------------------------------------------------1-------------------- FINAL INSPECTION BY-------------- -- ----- -- ---- -- ------------- Date-----------------/6 __--�o SAN JOAQUIN LO AL 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 E$-9-2M , Revisea ;-57 F.P.CO.