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APPLICATION FOR SANITATION PERMIT Permit No. -_--____ (Complete in Duplicate) - Date Issued -0/i-?----- 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 �_lP --------------------- � Owner's Name--------------------_r L�-. - LC-/�f ------------------------ Phone.c�i e--- Address--------------------------tel--.27 --------- .G= - ----- z Phone. f�-, Contractors Name--- --- - -4---�-'L----f---� - - - -----'�`---- - - ��---------------------- Installation will serve: Residence C, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _3___ Number of bedrooms___-- Number of baths -. _ Lot size ----&---lx' ' r________________-__ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ________ ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ NoK New Construction: Yes ❑ No K,_,,'FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Tank: Distance from nearest well_________________Distance from foundation________--__--___-_ Material------------------------------- kpv"" . �[i] ; No. of compartments-- -----------------`-- Size--------------------------------Liquid depth--------------------------Capacity----------------------- osal Field: Distance from nearest well------Z4-----Distance from foundation-_/o Distance to nearest lot _lin�e__ Number of fines__________ Length of each line__?__ __ ______.Width of trench____ _`______._______-.-_ Type of filter material.____ C1�fDepth of filter materia --- Total length______l�_ _---------------------- Number _____- -_-.-- Seepage Pit: Distance #o nearest well_--,�AO.S________Distance from foundation___.,.�f1___-----Distance to nearest lot line----7_________ �' Number of pits------ Lining material___l +� __-Size: Diameter------- p C:;;? ----Depth -- --------------- Cesspool: --- - Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------._-_______.___-_- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest we]-------------------------------------------------Distance from nearest building_____-__________________-_____.________._. ❑ Distance to nearest lot line----------------------------------------------------------------------------------- Remodeling and/or repairing {describe: ............................................. ----------------------- }----- •------------- -- - - ----- u ?' _ --��-------- ------- - --------- ----- ---- ------------------------------------------- ------------------------ Ihereby certify y that I have prepared +his application nd that the work will be done in accordance with San Joaquin County ordinances, State laws, d rules and regulat'o,s of the San Joaquin Local Health District. (Signed)-------------- o -- - -- ---- �C_/L--� --'-_-,��-P.^- --------(Owner and/or Contractor) By:. �G- •---------------------------------------------- (Plot plan, showing size of lot, location of syste in relation fo wells, buildings, a+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-� .- - ---------------------------------------------....................... ----------- DATE-_�-------•-•---------------- REVIEWED BY - DATE 17---------------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------ -------------------------------------- DATE------ f (trations and/or reco e,dati s__ __________ __ - ! ' --------1--- z_ _`_ __r .( ------------------------------------------------------ ---•------------------------._..--------- a -------------------------------------------------------------------------------------------- ------------------.-----------------------•----------------------------------------------------------------------------------- I ' / / / FINAL INSPECTION BY:.---------- 2,r tJ Date_ _� ----------.7 . ------ 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 Revised 1.57 FY CO.