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APPLICATION FOR SANITATION PERMIT Permit No.&_:Y_ov _____________ (Complete in Duplicate) j ,. Date Issued __) Joaquin Local Health District for permit to construct and install the work herein described. Application is hereby made to the San aq p , This application is made in compliance,with County Ordinance No. 549. JOB ADDRESS AND LOCATION--_-----------?---^l�:__...._ ��--�Q •-•------------------ Owner's Name = V` .Iv+� h-----••---------------• = Phone Address-------------------------------------------livi-.-r-- -N,�------------------------------------------------ ---------------------------------- ------------------•------------------------------ i Contractor's Name--------- ---------------------t •--------------•---------- ------------------------------------------------•------------------------•--- Pone_-•----•- - ----------•-------- t�a Installation will serve: Residence _Apartment House-E] Commercial ❑ . Trailer Court ❑ Motel ❑ Other ❑ ' � ° Number of living units: ___._:__ Number of bedrooms __I_____ Number of baths ___I--- Lot size __________ --`--------------------- __ _____ Water Supply: Public system 'D 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 5] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_______.0---Distance' from foundation__.___[_ ________-Material____.______r(_ __._--- --'--- No. of compartments-'___'_fir------------Size--- - --- -- -- ----Liquid depth--------h)_`1----------Capacity-------- Disposal Field: Distance from nearest well____._.1�___Distance from foundation_______------Distance to nearest lot line,__________ ber of lines--- :----�----- _------Length of each line---.-------_lm_0----------- Width of french--------- ------------------- Num Type of filter material------V-1_-_____-____Depth of filter MateriaL______��"__:_____Total length______________ 4�_._________________ 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--------------------------------------Depth--------------------•-------------------------------Liquid Capacity.- -------------------------gals. Privy: Distance from nearest well---------------------------------------------------Distance from nearest building-------------------------------------- : ❑ Distance to nearest lot line------------------------------------ ----------------------------------------------------------- 1-------- ------------------- Remodelingand/or rep iring (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- y -------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------•-------------:--------------- f--1 IJ 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 r gulationsf the San Joaquin Local Health District. -W -'(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--------- BUILDING PERMIT ISSUED------------ DATE--------------------- r ------.------------ Alterations and/or recommendations------------------------------ ------------------......--------------------------------------------------------------------.---••--•--••------ -------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- '--------- •---- ------------------------------------------------------------ ---------------------------------------------------------------------- -------------- ---------- --- U' FINAL INSPECTION BY--------------------------- ---f----kxtA- --- Date----------------- - ------- - •---------------... 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 E$----9-2M 10-52 Revised W-2100