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APPLICATION FOR SANITATION PERMIT Permit No. _7_3-.______ (Complete in Duplicate) Date Issuedr0__ --[4—T r � j f 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 LOCATION--- --_ - _-- ---------; --_ .� -------- Owner's Name • = ------------------ Phone -------- Address........................................ ------'--------------------------------------------------------_--------------------------------------------------------------------------------- Contractor's Name---------------- -------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ApartmentHouse ❑ Commercial ❑ Trailer Court E] Motel ❑. Other ❑ E Number of living units: _ �___ Number of bedrooms_� I'fumber of baths _L_:___ Lot size -------- ------->�---__ - _____________ Water Supply: Public system 'Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil"fo`a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobear pan ❑ Previous Application Made: Yes ❑ No New Construction: Yes o ❑ SNA TYPE OF INSTALLATION AND SPECIFICATIONS: �A (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Ir .. Septic Tank: Distance from nearest wells' JJ _Distance from,-foundation-/Q_________-Mat eri {-___ ____ ________ No, of compartments___________Size---- h'_1 -_Liquid depth________ --------- Capacity -_� Disposal Field: Distance from nearest well-- __Distance from foundation___/&--_--_----Distance to nearest lot lin __ _ _ ------- Number of lines________________ ____ _____ Length of each line------/ �___ idth of trench________"`__ ______ _______ Type of filter material____ ____ -1e L Depth of filter material____I_2o__.____ Total length ___ __ i Yp � � �(,� p � ---- g � � ------------ Seepage - . Seepage Pit: 'Disfance to nearest well---------------------- from foundation--------------------Distance to nearest lot line----------------- i' ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth,_-----------,--- --_-.---- CesspooL Distance from nearest well-----------------Distance from foundation___-----------------Lining material _________________`_____-___-___. Size: Diameter____------------------------ - ____________De th----____--_ _____-______.__-_-_ _________Liquid Ca acit als - Privy: ,a Distance from nearest well-------------------------------------------------Distance from nearest building__________________=f'_____-_.___-__. ❑ Disfance to nearest lot line-------------- ---------------------------------------------------------------------------------------------------!�:------------------------- l Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------------- F ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re ulations of the San Joaquin Local Health District. (Signed)-----A/W-------- i ----'-----(9:1--------- -- --------------------------------------------------------------------------------------(Owner and/or Contractor) By:----------------------•---_..... -----------------------------------------------------------------------------(Title)---------------------------------------------------------------- (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----------- -- ---- ---- ------------------ REVIEWEDBY------------------------------------------- ----------------------- ------------------------------------------------------- DATE----------------------- ------------------------------------ BUILDING -------------------- ---- --•- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------------- DATE---------------------- ----- - Alterationsand/or recommendations------------------------------------- ----------------------------------------------------•--------- ------------------- --------------------------------- ---------------------------------------------------------- -----------------------------------------------------------•------------------------------------- •-------•------ - ._ - - -- -------------------------- ------------------------------------------------------------- --------------------------------------------------------- --•------------•------------------------------------------------------ ---------------------------------------------------•------------ -------- ----------- FINAL INSPECTION BY:--------- .__�___'_----------'-------------------------------- Date----------- ------------ --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oafs Street 132 Sycamore Street 814 North "C" Street t Stockton, California Lodi, California Manteca, California Tracy, California y E$-9-2M 5.51 Revised W-2100 4