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' APPLICATION FOR SANITATION PERMIT Permit No. ... _. -__T-_ (Complete in Duplicate) f/-• (j ' S` 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 with County Ordinance No. 549. J08 ADDRESS AND LOCATION -- -- --------------------------- -- ----------------------------------------- OwnersName---------- --------------------------------------------------------------------------- Phone.-2-4 ------- Address---------- -------- •------- ----------- ---------------------------------------------------------------------------------- -------------------------------------------- { Contractor's Name------- --------------------------------------------------------------------------------------------------------- Phone.-------------------------------... Installation will serve: Residence n Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motels`❑ Other E]Number of living units: _/---- N.umber of bedrooms _�7 _Number of baths ----- Lot size _____---G__:-X ----------------- Water Supply: Public system OK'Communify system ❑ Private ❑ Depth to Water Table ________ ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E4--I9-ardpan ❑ Previous Application Made: Yes ❑ No [!J-�New Construction: Yes No ❑ TYPE OF, INSTALLATION AND SPECIFICATIONS: 11V. (No septic tank or cesspool permitted if public sewer is available within 208 feet.) p f No,ance from nearest weli_ n_�_.____Qistan e from foundation__ ______.-___Material ___:_ _f________'__:____ Septic Tank: Dist [ ,of compartments-------� -----_-----Size--- -Xl_).1�___----Liquid depth-3_�?--___-_----Capacity---- --a_-D----- Disposal Field: Dis7ance from nearest well-->�--------Distance from foundation__ ..........Distance to nearest lot line��_�d_ r Number of lines_____________________ __ Length of each line---1_ QG_ -_�+__`�___.Width of french___ Q_��__ Type of filter material-: ----Depth of filter maierial---__�'_--------------- otal length________-__--___:___________________--__ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lof�.line_______________ ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Dept h 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---------- ---- --------------.-------------------------------------------------------------------------------------------------------------- Remodeling and/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 regulatio of the San Joaquin Local Health ©isfrief. __-___________________________________Owner and/or Contractor (Signed) ' v ( / I Signed ------. 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 k DATE ' �. BUILDING PERMIT ISSUED----------------------------------�-------------------------------------------------------------- DATE.----------•-------- -- Alterationsand/or recommendations----------------- ----------------------------------------------------------------------------------------------------•----=-------•------------------------ -------------------------------------------------------------------------------------------------: -------------------------------------------------------- -------•---------- ----------- ----------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------•---------•---------=-- ----------------------------------------------------------- ------ - FINAL INSPECTION: J BY:._--- t - --------------- ----- ----------------------- 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 y r ES-9-2M 8-51`Revised-V-2400