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APPLICATION FOR SANITATION PERMIT Permit No. -(Complete in Duplicate) 1 -(9 Date Issued R _ � _ _ ------ Application is hereby made to the San Joaquin Local,Health District for a permit to construct and install the work her$in described' This.application is made in compliance with County Ordinance No. 549. HIJ 774<_-,f It JOS ADDRESS AND OCATION---------- ----- - -- ---------------- ---------------------------- Owner's Name----- ---�- ------------ -- ---- ---- -----:.----------------------- ----- Phone ---------- -- 'I_ 13 8-----•-------- ------------------------- .---------- - Address______ _______ ---- ----- ---- -- Phone-------------------------------- Contractor's NameInstallation will serve: i Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court X Motel D. Other ❑ Number of living units: ______-- Number of bedrooms -------- Number of baths ________ Lot siz ___+y___ ______ s - - ---------- Water Supply: Public system ❑ Community system ❑ Private [ r Depth to Water Tail _., Character of soil to a depth of 3yfeet: Sand ❑ Gravel ❑ Sandy Loam, Clay Loam ❑ ly ❑ Adobe ❑ Hardpan.❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No x F s ❑ No TYPE OF INSTALLATION AND rSPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available.within 200 feet.) . Septic-Tank: Distance from nearest-well-________________Distance from foundation_--:_____.___--___.Material_-----_________-____.._____-_-__-__'_._____--_. N "salNo.'of com artments---- ---------------- Size------------------- •-- Liquid depth- Capacity' .____ Distance to.nearest lot Distance from nearest well_ .c0__._.Dis#ante from foundation}.____ ___ __ Number of lines--------I-------------------------Length of each lin ----- � Width of trench--- ----------_-------- "Type of filter matenaL__S_70r' veopth of filter material-------,�__ ---------Total length---------- 0_______________________ Seepage Pit: Distance fo nearest well___ -_=_ 4____r Distance from foundation----------_.........Distance tonearest lot line----------------- - ❑ Number of pits----------------------Lining'material-----------------------Size: Diameter------------------------Depth--------------------------------- T Cesspool: e Distance from nearest welL_.______1-------Distance from foundation--------------------Lining material___._________________--____•________. ❑ Size: Diameter-------------------�---------------Depth-------- ------------------------ ------------------ Liquid Capacity--- -.gals. fF -- T' �^� --_Distance from nearest buildin ► Privy: Distance from nearest well_- -------------= ---- ---------- --- � g-7-------------------------------•------.. ❑ .� ------------ ----------- -------------- - Distance #o nearest lot-line-----------=------------- - .. -`--�"-------------------- ------ Remodeling and/or•repairing {describe):--____..r----------------------------------- ---•-------------------•---•-••-------------------------------------------------------------------- __(� } ------------- •--------- -!--•-------- ------------------------•-------------- --------------------•-------------------------------- -'` I hereby certify that l 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 Sart Joaquin Local Health District, (Signed) ------ ----------- - -------_______________________(Owner and/or Con+racfor) BY: ! Title------------------------------------------------------------ -- -- _ ( ) (Plot plan. showg size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). + ( 4 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------------------------------------------- ------------ DATE------------- REVIEWEDBY------------------------------------- ------- -------------------------- -------- DATE - -- �• •__ BUILDING PERMIT ISSUED------------------------------ -- --- -- --------------------------------- DATE------------------------- ----- r---- -------------- -- --•---- ---------------------------------------------•....... -------------------- ---•----------------- Alterations and/or recommendations- -----------------------------•------------------------------------------ ---------------------------------------------------------------- FINAL INSPECTION BY------------------- --- -- ------- Date---- _ = SAN JOAQUIN LOCAL HEALTH DISTRICT ( 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California s Lodi, California Manteca, California Tracy, California ES-9-2M Revised +-57 F.P.CO.