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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) (� � ' Date Issued _--- 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-_-- �__-___ ,• --_-_ = Owner's Name------------- a _ ----------------------------------------------- on Address &Xk9 - � Contractor's Name--- --------- --------------------------------------------------- Contractor's --------- - -- ------•------ ' , `l��- _l.� � �� .c' Phone .-- laJ Installation will serve: Residences`; Apartment House ❑ Commercial E] Trailer,Court E] Motel El Other El., ` Number of living units: -__� Number of bedrooms -- Number of baths _1--- Lot size _ ------ Water Supply: 'Public system Community system ❑ Private ❑ Depth to Water Table'Sldit., Character of soil to a dep+h of 3 feet: Sand 0 Gravel (] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes I] No New Construction: Yes E-] No)( FHA/VA: Yes ❑ No�. TYPE OF INSTALLATION AND SPECIFICATIONS: is (Np septic tank or'cesspool permitted if public sewer-is available within 200 feet.) m Sep a Distance from nearest well-----------------Distance from foundation-------------- Material--:__----__--------___----.__---_.___-.-__--"- No. of compartments--------------------------Size-_..-----------------------------Liquid depth---------- Capacity i sa eld: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line__--__-..---.-._. ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench.-----------------•--- -- Type of filter-material-------------- ----------Depth of filter material----------------- -_Total length-:--..--.-s.-_-______--------------------- r Seepage Pit: Distance; to nearest w _ - all---- 40WO-Distance m foundation----�-_.._•.Distant to nearest lot line_�- Number of pits------X . f--/__-:------Lining material---- IKx----_S'ize: Diameter__-- �--- ------.Depth-----2, ~---------------- \ Cesspool: Distance'from nearest well_"---------------Distance from foundation--------------------Lining material----------------- --------------- ❑ Size: Diameter-------------------------------------Depth-----------------------------------------------------Liquid Capacity----------- gals. Q Privy: Distance from nearest well-------------------------------------- ---------Distance from nearest building ❑ Distance to nearest lot line------ ------------------------------------------ - ----------------------- Remodeling and/or repairing (des ibe):------- '_-- I c ------------------- ---------------------------------------- - R—` --------- - -- -------e---- - ordinances, State lasand have nT red tions li of- - a- --- h h -- o - ill •- - n ac -- Sa -- -- n -- ---------- ----------------------------------------------- ----------- --------- --------- I herebycertify-that I have r ared this a lication hat the work will be done in accordance with San Joaquin,County n J aquin Local Health District. (Signed)----------------------- # ----- ----- -- --� {--------- .r --_-{Owner and/or Contractor) (Piot plan, showing size of lot, location of system in.relation to w s, buildings, etc., can be placed on reverse side). I S y FOR DEPARTMENT USE ONLY APPLICATIOW ACCEPTED BY-- ------------ ------------------=---------------------------- - 6— - --------•------- ------ DATE.........---------------------------------------------- REVIEWED BY ----- --------------------------- ------------------------------------------- DATE--�,�----------------------------------------------------- BUILDING PERMIT ISSUED-------- --------------•-• ---------------------------- DATE---�—' Alterations and/or recommendations: `----------------------------------------------- i -------------------•----------------------------------------------------------------------------------- - ---------------------- - ------------------- ---------- -•------------------------------------------------ FINAL INSPECTION BY:--- ;_ - ._r+ u ----------------------------------- 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 E5-9-2M , Revised 1.57 F.P.CO. ti.