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APPLICATION FOR SANITATION PERMIT Permit No. .. --� --- (Complete in Duplicate) Date Issued .-'r? Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This-appli cat.ion..is-made incompliance with ounty O.dinance, No. 549. JOB ADDRESS VD LOCATION ---- ------- ---- ----- --- Owner s Name.--- --- - ------------------ ---------- ------ - Address ---------------•------------ ----------I--------------------------- ------ �`'� Contractor's Name Phone ` t P___ _-.------ = i Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other Number of living units: j-___ Number of bedrooms _c3_ Number baths ___ _ ____ Lot size ______________________- ------------------------ ----------- Water Supply: PublicsY stem ❑ Community system ❑ Private [Depth to Water Table -------- ft. Wa Character of soil to a depth of-3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ € Previous Application Made: Yes ❑ No Q` New Construction: Yes M/No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.} Septic nk: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- 44 -__________ __._-__-_____--_______________, No. of compartments-- Size--------------------------------Liquid depth-- --------------•-------Capacity---------------- -' Q'spos JF�e Distance from nearest well-___: --Distance from foundation_____ Distance to nearest lot lin __ ______________ Number of lines---------- •7 Length of each line----_________/�+_ Width of trench-----_-_-- ;T------------------ Type of filter materi + Depth of filter materEal_______�-; ....Total length______ ------------------ - Seepage Pit: Distance to nearest well_______________ _____D'stance from foundation___________________.Distance to nearest lot line_.._____._______ ❑ Depth Number of pits---------------- -----Lining material----------------------- Qiameter__--_____________ --- _, .. Cesspool: Distance from nearestwell_________________Distance from foundation---------------------Lining material------------.------------------- Size: Diameter---------- ------------------------Depth---------------- •----------- ---------- ------_Li quid Capacity--------------•--- ___-___--gals. k Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------------------------- )] -------------------------------------------- Distance to nearest lot line------------------------------------------------- ----------------•-------'------•-------- Re delin and or repairing (d s 'be):--- F - ------- --- -- -- -- --- ------------------ F _____ _ _ . F 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 rules and regulations,of the San Joaquin Local Health District. (Sign ad f - `'--- -------------- -----------------------------(Owner and/or Contractor) By:__-------------------- -- - - ---------------------------- -------- --------- ----------=-------------------------(Tit e)------------------ --------------- (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- -------------------------- - - - --------------------------- - ---------------------------------------------- DATE----- ----------------------------------------------- . REVIEWED BY------------------------------ - - - - ------------ - - - BUILDING PERMIT ISSUED--------- ------------------------------------------------ ------------------ DATE--------- ---k ------------- --- _______________ Alterations and/or recommendations----------------------- ------------ s – •---------------------------------•-- ------------------ ----------------------------------------- _� t �/ - _______________________________________________________________ --------------------------------_____________________________,__._________.. R9x�_:` Date------------� -----x ----- � FINAL INSPECTION BY------------------ ----------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y. # E5--9-2M 8-51 Revised W-2100