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APPLICATION FOR SANITATION PERMIT Permit No. ..... ....... (Complete in Duplicate) 8�r/S Date Issued -----------------T__-- 040 -0 Application is hereby made to the San Joaquin Loca! Health District for a permit to construe an install the wor herein described. This application is made in complian wi County Ordinance No. 549. JOB ADDRESS PU LO ATI &'d_4 -- ` . U -------------------------------- Owner's Na e ------------------ Phone--------------------------------- Address-------- •--- -... ---- - ------- -- -------- ---------- -- --- ----------------------------•----------------------•-------------------------------------------------•--- Contractor's Name---- -•-- - I------ - ------------------------------------------------------------------------------------------------------------- Phone.-----------•---------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: __i-_-- Number of bedrooms _ .- Number of baths _:_�--. Lot size Water Supply: Public system ❑ Community system ❑ Private `Depth t ater Table __;.____ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE, OF INSTALLATION AND SPECIFICATIONS: (No septic tank cr'cesspool permitted if ubyc sewe is available within 200 feeft) ] r Septic ank: Distance from nearest well o�istarocp f I f°unplation_/0--li _.Mater' L. ______ ____. __--_ ___________ No. of compartments----------------- ------Si e__________-_ -o+'__--,__.Liquid epth_- ------ ---------Capacity.__Q Dis os Field: Distance from nearest w I1672___- istance from foundation_t __ "` Distance to nearest kotfne_XIII- °i" Number of lines__________ ----------Length of each line------ Width of trench__________ ___ Type of filter materi - s Depth of filter mate ------ -__.__Total length-_--_------�_ _ __________________ Seepage Pit: Distance to nearest well---------------------- from foundation_-__-_-________---.Distance to nearest lot line------------------ - t] Number of pits----------------------Lining material-----------------------Size: Diameter-------------- ------- - Depth---------------------------------- Cesspool: Distance from nearest.well------------- ---Distance from foundation _ _ ___________-_----- Lining material_ ______ ________---_-----_---_.___. ❑ Size: Diameter-------=---------- --------------------Depth----------------- ---------=--- - -------------Liquid Capacity----------------------------gals. . Privy: Distance from nearest well--------------------------------------------------Distance from nearest building---------------------------._--__-_______-- \ ❑ Distance to nearest lot line------------------------------------------- --------------------------- ------- ----=:=-------------------------------------------- a i -•-------------------------- ------------------------------------------------- ---- - -Remodel�g a , /or re-airin (�bse):__--_._` -------------------=----------------------------------------------------------------------------------- --------------------------------------------------- -------------------------------------------------------:---------•----------------------•--------------------------------- 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 re ations of the San Joaquin Local Health District. ------------ ----- ----------------------- ----------------------------------------------------- Owner and/or Contractor Signed ( / By:------------------------------------------------------------------------------------------------------------------------------------(Title)------------•---------------------------------------------------1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y_ a FOR DEPARTME=NT USE ONLY APPLICATIONACCEPTED BY- --- --- -------------------------------------------------------------------------------- DATE— ------------------------------------------------ REVIEWEDBY------------- ------------- = -------------------------------------- --------------------=------------------- DATE__-7--�-------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-- ---rn- _-------------------------------------------- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------•------------------------------------------------ -------------------- ---------------------------------•• -----------------------------=-------- -------------------------•-- -----------•-------------------------------•-•-•------------• ----------------------------------------------------- i --------------- •----------•------•--------------------------------------------------------•--------------------------------------------------------------•----------------------------------------------- ----------------------- ------- ----------------------- ------------ ------ ----------------------------- ---•------------------------------------ i r 7 FINAL INSPECTION' BY:.. ----•--------------- Date �I 7 7" SAN JOAQUIN LOCAL 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 ES-9-2M , Revised 1.57 F.P.Co.