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APPLICATION FOR SANITATION PERMIT Permit No. _-__-- (Complete in Duplicate) Date Issued ` Application is hereby made to the San Joaquin Local Health District for a permit t construct and install the work herein described. This application is made in compliance with Counjy Ordinance No. S49. . 6F/4 r JOB ADDRESS AND LOCATION -- `' ' tI �� '� U�j? ----- ------------- r "Lp Owner's Name-- i. ! i -- ------ Phone----------------------------------- --------------------- ------------- Address. �---- _ - ------------ --------------------------------------------------------------•-•---- - 'd Ire----------------------------------------------- Contractor's Name �� Phone. - ---- - - - -• - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other t Number of living units Number of bedrooms -------- Numer o ofks ___.-__ Lot size .___. __1 ------------------------ Water Supply: Public system ❑ Community system ❑, Private Depth to Water Table �ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ 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 or'cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well-----------------Distance from foundation--------------------Material __:.--___-____---_.---____________--_--_-_-. No. of compartments--------------------------Size--------------------------------Liquid depth---------------------------Capacity----------------------- Distance ------------- ------ Distance from nearest weLI.0.0 -.._Distance from founclation_Z_0f------Distance to nearest lot line_`_. Number of lines_.____f__ n--- _ Length of each line-_-Q1I_!-------------Width of trench--- �i�_ -_------_-_____ !! ri ,f 0D ----------- Type of filter materialAf __Depth of filter material___f/__._______Total length_______________---__________. Distance to nearest well_ e. �J°----Distance from foundation._/__OQ-------Distance to nearest lot line- NumberPtt: of pits.----I---------------Lining material._---------Size: Diameter._A-_ .f.......Depth----cX% -----_------------- 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-_- ----------------------------------------- ----------------------- --------------------------------------------------------------- Remodeling /or repairing (describe :------- ---- ------- ---- ---------- Az; � - ------------------------------------ -4--—----- - ------- ---- - - -- ------- ---------------------- --- -------- -- -- ----�'------ --- --------------------------------------------------------------------------------------------------------------------------------------- -- I hereb certify that I have prep ed this application and that the work will be done in accordance with San Joaquin County ordinances, a s, and rules and regulations of the Sa Joaquin Local Health District. r Contractor (Signed)--- �'------ ---�- ---�-- - �'� ��tJ l CL��Jf/J/-}---------------- ------------------- ) By:---- --------•-------------------------------------------------- --- ----- ---- - ------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relati wells, buildingtc., can be placed,on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- - ----------- ---------------------------------------- DATE---------------- -- -------------------- REVIEWEDBY--'-------------------------------- ------- ------- ------------------------------------------------ DATE- --- -- ko-- --------•----------- BUILDINGPERMIT ISSUED------------- ------- -------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations: --i---------------- ----------------------------------------------------------------•--------------------------------------------------- ----------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------•--------_---- FINAL INSPECTION BY: ----------- ----------------- --------- bate �� 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 E5-4--2M Revised i-57 FY.CO.