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r gc� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) {� This Permit Expires 1 Year From Date Issued Date Issued __/ __ _6.. 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 AND LOCATION----------------- � ---------- c,. �` �f1c I �,-- -------- j Owner's Name--------------------•----� _ .. .....-�•------------ -------------- Phone.---••-----------------••-- Contractor's Name ----------------- -•-----••--•-------------------- Phone ------------------------- Installation will serve: ResidencApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' i Number of living units: ____/-_ Number of bedrooms___ Number of baths _______ Lot size ____-_ra�U -- _ � G_________ Water Supply: Public system ❑ Community system ❑ Private $?� Depth to Water Table .�ft. j Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No,K New Construction: Yes K No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitte'd if public sewer is available within 200 feet.) , { i Septic Tank: Distance from nearest well_________________Distance from foundation-------------------Material------------------------------------------------- No. of compartments-------------------- ----Size---------------•----------------Liquid depth-------- Capacity--------------------- Disposa Field: Distance from nearest well-_%`__Distance from foundation----fU---------Distance to nearest lot line,------ Number of lines___-__________f--____-__T Length of each line______- -�____-_.Width of trenchs_____________ Type of filter material__ .r___f_�__-_Depth of filter material-----_- _________Total length___.;L;_-_�?_______________ Seepage Pit: Distance to nearest well------- 00_______Distance from foundation____. Distance to-nearest lot line_______Z�_. Number of pits. in material_/�a _____.-Size: Diameter. til-p __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------------------------ --- --------------------------------------------•--------------------------•---------------------------------------- Remodelingand/or repairing (describe):------ ------------- ----------- ---------------------------------------------------------------I----------------------------I--------------------------- 4. ---------------•------------- --------- --------------------------------------- •-- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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, an rules an regulatio of the San Joaquin Local Health District. (Signed)------------------- -c - ----- - --- ------------------------------------------------- (Owner and/or Contractor) y By:------------------------- ---------------------------------------- ------ ------------------------------------------------(Title)--------------------------- - -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY--------- - ---------------•------------------------------- DATE------- ' �� 4----------------------- " # REVIEWEDBY--------------------------------------------- ---------------------------------I---------------------------------------------- DATE------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE-------------------------------------•----------------------- Alteratio s apd/or recomme datio s:____---____-____-______ _ Ae ...... ----------------------------•---------------------------------------------------------------------------------------•---•--------------------------••---••--•---------------------------------- ----•--•------------ ------------------------------------ ----------- h _________________________________________________ ------ ------------________---_-____-._ __________ __._ ________________-_____.________.____-_________.____-__-_________-_______-_-_---___-_-_-_________--_______-_____ M i U .- FINAL .INSPE ON 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 8-'59 F.P.Co.