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t r 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 LOCA TION i � Owner's Name. -. ; -- -------------------------------------------------------------- 'Phone-- ��Address ✓ ¢ �- �' --------------------------------*-------------------------------------------------------------------------------------------------- Contractor's Name------- y ------------ Phone..--------------------------------- Installation will serve: Residence ®. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ---- Number of bedrooms ---1---Number of baths ---L_ Lot size ------ __________________ Water Supply: Public system ❑ Community'system ❑ Private D4,-. Depth to Water Table 2_3__'ff. Character of soil to a depth of 3 feet:- Sand ❑ 'Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9- Hardpan ❑ Previous Application Made: Yes.❑ No 0;�_—New Construction: Yes H_ No ❑ oFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearesr well_________________Distance from foundation_-:.__-_____._____-Material--_-______-.-...___.____-._______----..___-__. -- Size-----------------------•- _ Liqu depth Capacit , 0 of compartments__.__.,..___._.___ _ Disposal Field: istance from nearest well..... Distance'from foundation.- ---. _-__-_--_.Distance to nearest lot line e4 I---Xi;�_._�_ Number of lines-----_------�__�._f ______-___Length of each I;ne_____ _.............-Width of trench.-----G-_ yp ,i--..___5.I�Depth of filter material-.-,._ __ _Total length �._�: ------------- T e of filter material �-rs�-------- g -----•--------- 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-------r_--------Distance from foundation--------------------Lining material-------------_________________________ f ❑ Size: Diameter------------------------------`-------:.Depth-----------------------------------`-------------=----°Liquid Capacity----------------------------gals. Priv❑ Distance iro s o nearest-lot nearestlin _---- - --- ---- well e - - ------------------------ _ -----------------------Distance from nesrest building---------------------------------- Distance Remodeling and/or repairing (le scribe):---------.----------_ ----- •---------------------•-------•-•--•-'•---------------------------------------------------------------------I---------------------------------------- --------•------------•._-•--------------------------------- ---------------------------------------------------------------------I--------------------------------------7--------------------------------------------------------------------------------------------------------------- _____________________________________________________i.___-----__-________......_-_______________-___________________.--.___.__________--____-_--_____----•--- ___-______._-______-_._______--._____.__.._____.________._--__ I hereby certify that I have'prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, Stat aws, and rules and regulations of the San Joaquin Local Health District. s -- ------------0rand/or Can rector (Signed).. ---- - ----------------------------- -------- --- BY� ------------------------------------(Title)------- --------- ------------------)- (Plot -- --------------- (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 6-r-7----------------•-------- REVIEWEDBY------------------------------ -- -------- - - ----------------------------------- DATE---'}_ . Or BUILDINGPERMIT ISSUED---- -------- - --- -----------------------------•----------------------------------------- DATE-------------------------------------------------------------- Ifer ions and/or recommendat' ns: -------------------•--•-------------•------------ • ---- - - ----- ---------: -- ------ ---------------- --------------------- ------------- �-� F - FINAL INSPECTION BY:.. -----•---------------- Date------a ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814'Norfh "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2 M . Revised 1-57 F.P-M f ,