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APPLICATION FOR SANITATION PERMIT PermitNo. ---_______-- (Complete in Duplicate)-Date Issued _____________ Application is hereby made to the San Joaquin Local Health District for a permit to construct and instar e wherein described. This application is made in compliancerwith County Ordinance No. 549it . � � -- `- ---------------------- - •------- JOB ADDRESS A,1) LOC TION__ _ -_____ - Owner's Name----'q---------�- - - ------ --'------- --- ---- �.- - --�--�t-- -- - ---------I,?----------------------- Phone------•----=---------- -------------------------------------- ---•--- Address.-------'�`----¢--- --- --- -- ---- ---------------------- --------------- -•-----------I-=---•--------•-----------••-----------------------------•-----•-•---------------. Contractor's Name- ------- -- --------------•----------------------- ------ Phone.---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trail ��/Court ❑ Motel ❑ Other El Nurimber of living units:+Vc:rnmuriity mber of bedrooms__._ Number of baths Lot sixe __®. -- --- -----1--0-��---------------------= Water Supply: Public system system ❑ Private ❑ Depth to Water Table -------- ft. Character,of soil to a`dep+h of Meet:- Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes I] No•R� New Construction: Yes No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted 0 ublic sew1r is available within 200 feet} - ]� � ` 7�tsw' u��, Capacity. W . Septic Tank: Distance from nearest well__ ____ •istanc, from f undaflon_�+�--------------Mat i I.___-_-______ ------_______ ____ _� Li uid e tk�_-----_ No. of compartments41e, q p. � -Dispos I'Field: Distance from neareDistance from foundation_]V-�istance to nearest lP�' lireFTNumber of lines------- -------- Length of each line------s__.___-_._ Width of trench------ __Type of filter mater -Depth of filter material_-_-_____ _______._Total length___________ __ ---______..__._Seepage Pit: Distance to nearest welly__ """Distance`from'foundation--------------------Distance to nearest lot line______________-_- ' ❑ dumber of pits--------- ------------Lining material-----------------------Size: Diameter------..----------------Depth--------------------------------- Cesspool: Distance from near l t well-----------------Distance from foundation--------------------Lining material_____-____-.--__________.__________. . ❑ Size: Diameter----------------------=-----•---------Depth----------------------------------------------------Liquid Capacify----------------------------ga Privy: Distance from nearest well------------------"------------------.----------Distance from nearest building---------------------------.----------.: s ❑ Distance-to nearest lot-line._----_----------i-- ------------------------------------------------I---------------------------------------------I--------- Remodeling - --- ------------ Remodeling and/or repairing (describe) -------------------------------------- ------•------------------------------------------•---------------------=-----..-..------•----_. ----------. Q A - C 4_ ..._.1 -----------•----------- ------------------------- -------------•__-=------------------------------------------------------------------ r - _______.. _ _____________f________________-__________________.__-_______________.._________.._____.______________.._______.____________.________._______________._...____._________________________-___�________._ . I hereby certify that l have-prepared this,application and-that the work will.be done in accordance with.San Joaquin-County ; ordinances, State laws, and rules and regulations of +he San Joaquin Local Health District. . Ira �,,(, --------------------------------------------(Owner and/or Contractor) (Signed) � � ---- ------------------------------- . ,.� I �. By:--------------------------------------•----------•----------------------------- -- ----------------------------------------------(Tit e)--"----------------- ---- (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 ACCE?TED BY --- --------------- ----------------------------- ------------------- ------ DAT DATE ' REVIEWED BY ---------- ,�, ----•---------- BUILDING PERMIT ISSUED___ DATE--.________ --------------------------- -- -------------------- - ---------------------- ----- ---- Alter t'on and/or re _______________co endations_ _______•�--__ -_- �� -- ---------------------------------------------- ------------------------ -------------------- --------------------------------- -------•--------------------------------------------------------------------------- ------------------------------------------- ---------------------------- ---------------------- ---------- -- ---------------------------- ----- ---------------------------"--- ----- FINAL INSPECTION BY:-_-- ------------ Date T � - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 FYCO. ...,..6Ne .F