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APPLICATION FOR SANITATION PERMIT Permit No. �Q_ .L`�• ___ ?Yh -�y (Complete in Duplicate) _ „ Date Issued '____ _ 5 Application is hereby made fo,the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance wit Ordi nce NO._549. JOB ADDRESS AND LOCATI N_ 'T------ --- ---�-------- --- - ----------- - Owner's Name--------------------------- l ------.--- ------------------------ ---------------------------------- Phone- -----------a'�-4� --7 X [ Address--------------------•---------------------- —'------------- - ------------------------- -------------------•--------------------------••-------- Contractor's Name-------------------------------------1' "----------------------------------------•------------------------------------ Phone----------------=-----•----------- Installation will serve: Residence) Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: t_ _-- Number of bedrooms - 8-- Number of baths /___ Lot size ___? ____typ___ __________7__________ ; 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 [3 -Clay E] Adobe.g Hardpan ❑ Previous Application Made: Yes ❑ No..0 `T New Construction: Yes 5?, No ❑ FHA/VA: Yes;K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic_ Tank: Distance from nearest well----- __.____Distance from foundation---/ -------.Materia_ __.__________� No. of compartments________ __ ___--_ ------------_ __ Disposal Field: Distance from nearest well...-e -----Distance from foundation--,, oundation___ ,______Distance to nearest lot line_�_� -- Number of lines__________ ___________________Length of each l-me____-_--___ �- Width of trench---------�'- -r_______._ Type of filter material- Depth of filter material____._�e__--__._Total length-------------;;�nY�o_---- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__._..._____----___._______-____.___. ❑ Sze: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------------------------------------ Distance ---------------------------------- Distanceto nearest lot line ------------------------------------------- ----------------•------ ------------ -------------------------------------------------------- Remodelingand/or repairing(describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- y ------------------------_1------------------ ------------------•---------------------------------- _____________ ____----._____________________________-______________________________-___-______________________-___--_______.__._________________________-_._.-._________________________-.-__._ ---------------------------------------- ---------1--------------------------------------------------------------------------------------------------------------------------•-------I----------------------------------------- I hereby certify that I have prepared this application and fhat the work will be done in accordance with San Joaquin County ordinances, State aws, 'rul s and regulations of the San Joaquin Local Health District. $i ned _____-_________ ___ _________________(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-------- ----------------- REVIEWEDBY-------------------------------------- --------------------------------------------------------------------------------- DATE------ ---------------------------------- ---------------- BUILDINGPERMIT ISSUED--------------- ------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------- --------- -------•----•------ ----------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- �-t--, ------ - ----•--------- ---- ----------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.. --- Date. ---'D_'�/�' -^-� -------------------------------- SAN ----- - ---------------•---- SAN JOAQUIN LOCAL EALTH 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 Revised 1.57 FY,CO.