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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 to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-- * �J-.�� ----------------------------- - '".�--- ------- � W—y-,�, , Phone___ Owner's Name 1-L1 � Address ----- - -------------------- -------- ---------------------------------------------------- ------ ��s , Phonel- �� Contractor's Name-----------------------4.1 ------ -------- - Installation will serve: Residence U1/Kpartment House ❑ Commercial ❑ Trailer Court ❑ Motel P Other ❑.10, Number of living units: . - Number of bedrooms -Number of baths -1'--_ Lot size _It �:_-._.�---- ------ --- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table . 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.) c Ta k: Distance from nearesr well------- -------Distance from foundation_-_-_-__,---------.Materiai------.-_--__---------------.--------------_--. k� No. of compartments-------------------------Size--------------------------------Liquid depth------------ -------------Capacity--------- ------------ osal ield: Distance from nearest -well------------------Distance from foundation--------------------Distance to nearest lot line----------------- f Number of lines--------------:--=-----------------Length of each line------------------------------Width of french----------------------------------- �i Type of filter material------ -----------------Depth of filter materia l-----------------------Total length----------------------------------- --- Seepage Pit: Distance #o nearest well _-`Distance rem f undation-- - .._--.Distance to nearest lot line--- T �� Number of pits.-:- ---__--------__Lining material_ 'C -----Size: Diameter--_Z_�-----_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 lonline----------------------------------------------------------------------------------------------------------------------=------------ Remodelingand/or repairing (describe):---------------------------------------------------------------•-•----------•----.....------------------- -------•------------------------------------ ------------------------------------------------------------ --------------------------------------------------------------------I-----------------------------------•---------------------------------------------------------------------------------•-------------------- I hereby ce ify hat I have prepared jhis application and the+ the work will be done in accordance with San Joaquin County ordinances, Stat law , and rule and re tions of the San Joaquin Local Health District. o *---------- ------- -------- ---- -------------- (Signed) Contractor) ----------- - ---- ----- --------- �nd��or By:-------------------------------------------------------------------------------------- ---�-------- - ---------- (Title)- -� ------------------ can be Iced on reverse side). (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc. p ] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ DATE_. ------------------------•-----.---------------------- ------------------------------------------------------------- REV[EWED BY ._ 1 DATE-----� ---- - ----------- ------------ - --- ---------------- - -------- BUILDINGPERMIT ISSUED- �-- ------------------------ -------------------------- ----------------- DATE_ ---st----------------------------------------------- Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------- ---------------------------------------------- a ------- --------------------------=-------------------------------------------------------- ------------------------------------------ Z- = --------------------------------------------- --------------------------------•---------------- ---------------------------------------- ..-..-------- 1 ] _ .. FINAL INSPECTION BY:.. ={/ --------------------------------------------------- Date- ------------ '6 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 Revisea 1-57 F.P.CO.