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APPLICATION FOR SANITATION PERMIT Permit No. .l,.o �..... (Complete in Duplicate) Date Issued .4 ._f5.�.. 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 Ord' ante No, 549. JOB ADDRESStND L ATION•---.. ---'� —-- ----- ~ -------- - - - ------- - .''-----------------------------------•------------ Owner's Name ! -----•------ - -- ----------•- ------------------------------------------------------ Phone------------------------------------ --- Address........ a ......... ----------- Contractor's Name--- ---------------------------------------------------------------------------------------------------------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j---- Number of bedrooms ..------ Number of baths ._I__ Lot size ._- All _�' �SQ ---------------------------------- Water Supply: Public system &3--c-ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loarrt[-] Clay Loam [:] Clay E] Adobe�t-lardpan ❑ Previous Application Made: Yes E] No �ew Construction: Yes J21'00'No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- No. of compartments--------------------------�{ .w _ Size...----------------------------Liquid depth--------------------------Capacity--------............. Dispose field: Distance from nearest 11''G '1P._Distance from foundation-_�t�__�_-____Distance to nearest lot I'e...�'.___-_-- Tu e of filter materia ---Length of each line___3d ------Width of trench---•z ___ _________________ yp I______ __ _____ _ _Depth of filter material____ ---'-t____-_.Total length_....30.1_________-________---.---------------------------_ Seepage-Pit: Distance to nearest well----------------------Distance from foundation...................:Distance to nearest lot line-___-.--__---_-_- Number of pits----------------------Lining material--------_--------------Size: Diameter------------------------Depth------.___---._-____-_----_______ C sspool: 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-:------------------------------------------------------------------------------------------------------------------------------------------- r Remodeling and/or re airing (describe) - ------- ----------- -Grp-- -E------------------------------------------------------------- ------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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, and ules and r tions of the San Joaquin Local Health District. k(Signed)-----------_---------- � ---------- ---------- --------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------------------------------------------------------------------------------- -----------•(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -- ------------------------------------------------------------ DATE-------------j ------------ j REVIEWED BY---------------------------------------- - ----------------•-... DATE------------ --- �` r P BUILDING PERMIT ISSUED--------------------- -------------------------------------------------....... DATE------... --- - --------------------------- Alterations and/or recommendations:------ ecommendations: --------------------------------------------------------------------------------------------------------•--------------------------------------- ---------•------- ------------------------------------------------------ ------ -------------------------------------------------------------------------•-----••----•--------••----•----•--------•-------------••---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------•-------•--........... ----------•--------•---•-----•---•---- ------------------------------------------------ ----------------•-------------------------------------------------------------------------------------•---•-------•-- ------------------------------------------------------------------------------------------------------ ---------- -------------------------------------------------------------------------------------------------------- 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-9-21A ; Revised 1.57 F.P.CO.