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APPLICATION FOR SANITATION PERMIT Permit No. ID__ --r`_ (Complete in Duplicate) V5 /Q/?/v�Date Issued ------- - Application 1s hereby made to the San Joaquin Local Health District for a permit fa construct and install the work herein described. This application is made in compliance J1with County Ordinance o. 549.% JOB ADDRESS PaND LOCATION -------- - ----------- - ------------------ Owner's Name----- --------------- ------------------------- Phone ------------------------------- 9 ,� =--'>>�`?--- " = ---------------------- Address ------ ---------------- - -- ---------------- Contractor's Name--- -----•-------•----------------------------------------------------------------------------------------------- Phone ----------------------------------- Installation will serve: Residence Ef Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Ot er ❑ Number of living units:_�4ommunify umber of bedrooms ._ __ Number of baths __ --_ Lot size __�______�__�_ ___�-'`____,__ _ Water Supply: Public system system ❑ Private ❑ Depth to. Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay E] Adobe 2 ---Hardpan❑ Previous Application Made: Yes ❑ No [New Construction: Yes [`No ❑ # TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s;wer is available within 200 feet.//) Septic ank: Distance from nearest well___ .__ Distance fro �f6und pn____�-S./----_-_-Materi _____ ___________ ____ __ ____ _ �. K No. of compartments---------- - f Size---! = x ------- -Liquid dep}h Capacity l Dis offal Field: Distance from nearest well_)��_--__ Distance from foundation___9"6--t p r ____.Distance to nearest lot lif�_r�_________ ----- Number of lines___________ _ l.__.______ Length of each line --------- �__Q_l� _____.Width of trench________1_'7" Type of filter materia .___ �_ -- - - p l g 4.De th of fikter material --------___________Total len th________�. ____________________ 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 from foundation ------------------- .Lining material --------------------------------- ❑ Size: Diameter -------------------------------------- De th-=---------------------------------------------------i uid Ca acit --- als. pq p Y----- -- -- -- g Privy: (stance from near"est we 1 __________ _ __ _ is�a��rv�rest'btriiding_____- ❑ Distance to nearest lot line ------------------------------------------------------------------------ --- ---------------- Remodelingand/or repairing (describe):-----------------------------------------------•--------------------------•---------------------------------------------------- =----------------------- - - • - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - • -------- I ------- = - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ----------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ 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. (Signed)-� - ---��'� � ,--------------------------------------------------------------------------------------------(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 REVIEWED BY ------------------------------------ DATE---- lc ------------------------------ BUILDINGPERMIT ISSUED ------ ----------- -------------------------------------------------------------------------------- DATE----------- -------- - Alterations and/or recommendations---------------------------------------------------------------------------------------------------------- ...------ -------------- -----•------------ -------------=----------------------------------------------------•--------------------------------------------------------- ------------ -------------------------------------------------------------------------------- FINAL INSPECTION BY:-- .________-_�---------------=-------------------------- Date -------- !cS --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M 8-51 Revised W-2100