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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 pp p with County Ordinance No. 549. jQ JOB ADDRESS AR LOCATION--- - ='�!_' ;. -- --- ` ----------------------- - - - - -------------------------------------- Phone------------------------__----•--- Owner's Name_ --- :-�---.1�_l-------t-----�-�-��-,-------]-_--.-�--• -------�---�-• Address-------------------- � 9 --L•.% .."-'-----------------------------------•-•------------------------------------------......-------------------------•------ p Contractor's Name------------------------4-6 � �% i ' _�. �- ------------- Phone----------------------------------- Installation --•------- ---------- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___1____ Number of bedrooms _- Number of baths __.__-- Lot size _____ _ ______ Water Supply: Public system ❑ Community system ❑ Private [R/ Depth to Water Table _A_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public fewer is available within 200 feet.) f _Material_&�_ Septi Tank: Distance from nearest well__.. __________Distance from foundation______ ._____ ________ f No. of cbmpartments_._____�4 __Size_____�QC_ _ _____.Liquid depth_.______ ____________Capacity__ -_______ Dispos Field: DistancNumberofolnesearest- ell__--�'�=-=-Deja}� of om each line atcorny-----1�17-f-_=-_.Widthcofttrenchnearest--lot tline_____-�---.. Length f _ t` i ---------- Type-6f Cter material___.______Depth of filter material________l'g_______-Total length-------`_4PA-------------------------- Seepage ___,___- ___.____- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- F1dumber of pits----------------------Lining material-----------------------Size: Diameter--------------;---------Depth-----_a--------------___--------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______..-._____________.____-_______- ❑ Size: Diameter-------------------------:------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---- ---------------------------------------Distance from nearest building----------------------------------_--_-_. ❑ Distance to nearest lot line---- ------- ---------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------- --------------•--------------------------------------------------------- -------------------•---------------------------=-----------------------------------------------------------------------------------------------------------------------------------------------------•------------------------ - --------m------------------------------------------------•--------------------------------------------------------------------------------------------------------- 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 re6ulations of the San Joaquin Local Health District. (Signed) - (Owner and 4 � '} By------------------------------•---------------- ------------------- ------ - r ontractor I .. -------------------------- -----------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F FOR DEPARTMENT UXE bNLY APPLICATION ACCEPTED BY--------------------- -------- -` ----- y DATE_ REVIEWED BY----------------------------- - DATE BUILDING PERMIT ISSUED----------------------------- ---------------------' -._ :------------ DATE Alterations and/or recommendations______________________ _ ___ _'. .. ------------------------------------------ a z - FINALINSPECTION BY---------- ---- - --------- --------------------- Date--- l ------------ ------- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oafs Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M Revised 1-57 F.P.CO.