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APPLICATION FOR SANITATION PERMIT Permit No. ._______�� 1 r (Complete in Duplicate) 11 -w Date Issu lje-_ '--S r _ Applica+ion 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 LOCAfI�+JN___.!__ _ .____ _•---_- ---_-_ Owner's Name-_._. - --------•---- . ------- ----------- ------••-------- ------------------------------------------•---- Phone --------------- Address { j� Contractor's Name- - ------------------------------------------------------------------•----------•-----------•----- Phone.--•---•---------------•----------- Installation will serve: Residei?zl Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units: umber of bedrooms -------- Number of baths -------- Lot size ___.______r________________________________ ------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- 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:-N No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: \!` (No.septic tank for cesspool permitted if public sewer is available within 200 feet.) V` Septic Tank: Distance from nearest we}I_________________Distance from foundation___________--____._.Material______.__--.__________-_- ------ ----- Co No. of compartments------ ----- - ----- ¢e--------------------------------Liquid de th---------- --------------Capacify Dispos FiDistance from nearest wet Distance-fFom foundation ._ - Distance to nearest lot li e Number of lines---------- - - -- # I Length of each line___---_ Width of french___--- --44&jType of filter mater epth of filter materiall_____I_. -_--_____Total length ___________ 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-________________.Distance fr.om,foundation.----_._._.__----_Lining material--------.----------.------------------ Size: -_._____-_ _ __. ❑ Size: Diameter--------------------------------------De Depth------------ Liquid Capacity P -�,> q ----------------------------gals. Priv Distance from nearest well___________________-: _--- -- Distance from nearest building ❑ lot line_ -------------- -------------"�-.,.° ." " -------••-•-- ------------------•-----------------------•-- ---------------- i! � � I , s } Distance to nearest emokeling , /or� ng fdescrr el " ' ' --- - -e r � ----------F---------------------------`-------------------••---------- - ----.----' --�------------------------------------- ---------------- -=------------- - - -- ---- -- ---------- ---- --- -- - ------------------------4----------- ----------------------------------------------------------- # I hereby certify that I have prepared this application and=thaf-the work will be done in accordance with San Joaquin County ordinances, State•laws, and rules nd re plafions f the San Joaquin Local Health District. �.�'-_ _.._ r r (Signed) w- ;�'�-=--'- ---- '= �._ = �.-'�------- =----------------------------------- -------Owner and/or Contractor) By`-----------------------------------•-------------------------------------------------------------•------------ ---------•-(Tiflei------------------------------------------------------- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings etc., can be placed on reverse side). 4 • � FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ ---------- ----- ----------------------------------------------------------.- DATE-�,•r--------------------- REVIEWED BY ------ - --- - ----- DATE---- -- # BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------I---'----------- DATE------- Alterations and/or recommendations:---------- ---------------------------------------------------------------- ----------- -•---------------------------- ------------------------------------- FINAL i INSPECTION SPECTION BY: --- Date------- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2N! Y Revised W-2100