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APPLICATION FOR SANITATION PERMIT Permit No. -_--_- (Complete in Duplicate) 1 q Date Issued ��----------------l 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 Ordinanc No- 549 JOB ADDRESS AVD LOCATION— �i � -- 1 Owner`s Name -- ----- ---------------------------- --------------------- --------------- ------------- -------- Phone ---------------------------------- AddreAddress ss------------ -------- . ------- -- --------- Contractor's Name -_ f-------------------------------------- Phone.,-------___z iS vZ l Y Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I-__-- Number of bedrooms ___3_ Number of baths ___j.-- Lot size -----------------------------------------------------------_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table,3---Q- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeN' Hardpan E❑ Previous Application Made: ,Yes ❑ No ❑ New Construction: Yes �q 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-------------------.Materiai---------------------------------__-------------- ❑ No. of compartments---- - ----Size--------------------------------Liquid depth---------------------- Capacity_ ___ -------------------- Disposal Field: Distance from nearest well --------Distance from foundation--------------------Distance to nearest lot line----------------- s ❑ Number of lines-----------------------------------Length of each line------------_-----------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material------------------------Total length-----------------------.----_---__-__----- Seepage Pit: Distance to nearest well---1'f1dl..--____Distance from fo nd�tion__� __'_:'__.Dis#�afce to nearest lot line-_--% .�_ i Number of pits---------/-----------Lining material-----�'G�G` -_::_Sizes.Diameter-_----i------------Depth- !J -.____-._____- Cesspool: Distance from nearestk( ,_----.-_-_-__Distance from foundation.-.--.------r_-----Lining material_----------------------------_-___. 4v ❑ Size: Diameter----- --------------------°)----- -Depth----------------------------- ------- ------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---- -----------------_----____-__-._---------._Distance from nearest building------------------------------------------ El _---_-__ _.________________.._.❑ Distance to nearest lot line--------- ------ ------------------ ---------------------------------I--------------------------------------------------------------------- I, Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ -------------------------------•------------------------ --------- -- ----------------------------------------------------------------------------------------------------------------- i! --------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 ru*ndlations oSan Joa in Local„Health District. (Signed) - --- --- ------------------------------ (Owner and/or Contractors , 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-- -77_,R!�-0--"----------------------------------------------------------------------- DATE------.. --------------------------- REVIEWEDBY------------------------ ------------------- -------------------------------------------------- --------- DATE.--------------------- � BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE--------------- Alteration and/or recommendations:-------- ------------------------------------------------------••-------------------------------------- --- } ---- ----- ----------------- v---,',�_------Y---------------------- --------------------------------- = = .> - .e -- - ------------------------------------------------------------- ---------------}-------------------------- ----------------- ---------------------------------- ---- -- ------ '��fJ ----- Q w -- - —----- '.�"�} - - ---------------------------- FINAL INSPECTION BY:------ Date---- '7- --- --�J y ------------------- 4,0_4 � - ---- - --- - SAN JOAQUIN LOCAL HEALTH DISTRICT • 130 South American Street 300 Wes+ Oak Sfreet 132 Sycamore Sfreef 814 Norfh "C" Sfreef Sfockfon, California Lodi, California Manteca, California Tracy, California i ES-9-2M Revised 1-57 F'�'P.Co.