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APPLICATION FOR SANITATION PERMIT Permit No. !J-_....- in Duplicate)(CompleteP ) Date Issued ----�X% 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 incompliance wit unty Ordinance No. 549. c:J4111sZg JOB ADDRESS AND LO T O *11 C4 ` Qgr Owner's Name------------ _ Phone--------------------------- Address---------- ----------- ------------------------------------- Contractor's Name-------------- - ---e7--- ---- ---------------- Phone..--------------------------------- Installation will serve: Residence El Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: --------- Number of bedrooms__ . Number of baths ..7--_ Lot size _ _ __ -------------------------------- Water Supply: Public system ❑ Community system ,Private ❑ Depth to Water Table 0- 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 [L�� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool Permitted if public sewer is mailable within 200 feet.) peptic ank: Distance from nearest well_________________Distance from foundation--------------------Material--------._____..__.-___----__________.___--_. No. of compartments- --- - ----------- ------ Size-•------------------------------Liquid depth-------------- ----------Capacity--------------------- _1� isp 1 Field: Distance from nearest well-__-- ---_.Distance from foundatior��+ --�_-__.Distance to nearest lot li�---�D__f___ O 7 � Number of lines---------- ---- --Length of each line------- of trench--__ __- ----------------_-_- Type of filter material- .Depth of filter material___-/a- !____.Total length----- -.------_----•______-_._ I Seepage Pit: Distance to nearest well____. ---------Distance _prom fou dation___--�AP_._.___.Distance to nearest lot line-___- size: Diameter '4- Number of pits------ ------------Lining materia Depth_. `- ? s----- Cesspool: Distance from nearest well-----------------Distance from foundstion-------------------.Liming material------------------------------------- 171 _-._____.._.-.------___ _._____--_❑ Size: Diameter------------------------- ------------Depth---------------------------------------- ---------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Disfance from nearest building----------------------------------------- 0. Distance ___--_-- _____________-_______- Distance to nearest lot line--------- - -A ---- -•----------------------------------------------------------------- --------------------- l� Remodeling and/or repairing (describe):------------------- ------- - —---------------------------------------------------------------- ---------- - --------------------------------------------------------------------------------- \ p ------------------------ ----------------------------------•----------•--------------------------------------------------------- t ! 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 r les and regulations f the San Joaquin Local Health District. i _ (Signed) -- -- ----- -------------------( ontractor) I9 )---------=---------- - ---- -- 1 By:----------------------------------------- ---------- - --- -------------------------------------------------(Title)---- - -----�-- - ---------------- (Plot plan, showing size of lot, l ion of system in relation to wells, buildings, etc., can be placed on reve side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY ---- -------------------------------------------- ---------------------------- DATE._s----------------------------------------------- - - REVIEWEDBY------------------------------ ----- ---- -------------------------------- ---------------------------- --------------- DATE_s�_ BUILDING PERMIT ISSUED------•--- ---------------------------------------------------- ---------------- DATES = Alterationsand/or recommendations------------------------------- -- ---------------------------------------------------•------•----------•---------------------------------------------------- ------- 1 ----------------------- -----------------------------------------•-----------------------------------------------------------------------------------------------------------•-------------------------------------------- r I ------------------•---------------------------------- -------------------------------------- ------------ ----- FINALINSPECTION 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 Traoy. California ES-9-21A , Revised 1.57 F.P.CO.