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APPLICATION FOR SANITATION PERMIT Permit No. d_ _U_,? (Complete in Duplicate) Date Issued --- -- 3_ s 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 A OCATION____ �J_ ,�j� Owners Name ------ ----- ------------------ Phone Address------ ----- Contractor's Name---- v~ 1 Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ETvlotel E] Other T ❑ Number of living units - Number of bedrooms®�y Number of baths -l-_YLot size ___o? _-_ _____ _________________ Water Supply: Public system ❑ Community system E] Private E] Depth to Water Table __ f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobelardpan ❑ Previous Application Made: Yes ❑ No New Construction. Yes ❑ No FHA/VA: Yes ❑ No Z� 't TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i Septic ank: Distance from nearest well-----------------Distance from foundation--------------------Material--------------------------_____.__-_-___________. 4 No. of compartments p ------------f--Size-----------------------•--------Liquid depth--------------------------Capacity--------------- ---, Dispo al eld: Distance from nearest wellv�� .__--_Distance from foundatio _ __ _ Distance to nearest lot line__�6v_____ 1 dumber of lines------------- Length of each line-------____-- $- -----.Width of trench-------- f r'-------------- Total length 4 Type of filter material__ .-. --Depth of filter material_____._ g ----------------------- : i ! d . . Seepag 4t: Distance to nearest well__�j.�a-___.-__Distance Z&O dation__��_______.Distanl�to nearest Ipt . t Number of pits-____�___________Lining material___ _Size: __.-_ ------ Cesspool: ___ Depth __________ Cesspool: Distance from nearest welL______________Distance from foundation--------------------Lining material___._-________________._____.______- ❑ Size: Diameter---------- --------------I- --------Depth---------------------------------------------------_Liqui.d Capacity----------------------------gals. Privy: Distance from nearest well___----------------------------------------------Distance from nearest building_*-_. .____________-_-________________- l ❑ Distance to nearest lot line-------------------------�----�----------- --•-- ------------------------•-------- h Remode}}ng and/or repairing (describe): A "�"{ ---------------------------•------------------------ ------------------------------------------------------------------------------------------------------------•--------- ---- ---- ------ ----------------------------------------------------- -------------------------------------- -------•------------------------------•----------------- ----•------ ----------------------------•------------- ----------------------•------------------------------------ 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,4anadules and regul tions of the San Joaquin Local Health District. (Signed) ------- ------------------ 1 -- ----- --------------------10 en' r Contractor) By:.-•-------------------------------------------- ---------- � ------------------(Title)----- �'7- - ---------------- (Plot plan, showing size of lot, locati of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- - - -----------------------------------------------. DATE------------�--J--- -- - -- - REVIEWED BY------------------------------------------- -------- ------------ DATE-----------f� --- --- ------------.. BUILDING PERMIT ISSUED------------------ --- ---- -----•------ ------- -- ---------------------------------------- DATE----- Alteratiand/or recommendation : ------------------------ ---------------------------------------------------------------•------------..._-------------••-------------------•------------- -•----------- -f, a-a---------- --------- --- ----------------------------•-••--------------------------------------- cam, o�A r-J �--�--- ----------- /� { ----- - -- ------- --- ------- ---------------------------------------------------------------------------- ------------------------------------------------------------------------------- FINAL INSPECTION BY: --- ---- Date- - ------------------ 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.