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r `-- APPLICATION' FOR SANITATION PERMIT Permit No. _._- _ . (Complete in Duplicate) Date Issued Applical-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 'LOCATOI ----- _-��-- ------------ - ----'--- ------------------------------- ----------------------------- Owner's Name------------ --- • : Phone------------------------------------ Address----------------- Contractor's Name-------------------------------------- Phone Installation will serve: Residence [j--'_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�4__ Number of bedrooms __,A. Number of baths A____ Lot size _______ Y-____-_6----___________--___..- Water Supply: Public system ��ommunity system ❑ Private ❑ Depth to Water Table -------- ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobep Hardpan ❑ Previous Application Made: Yes Er-No ❑ New Construction: Yes ❑ No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic_ Tank: Distance from nearesr well----j1Q---- .---Distance from foundation----It-----------Material--------��`�__._ °_._..__._- No. of compartments_____________'I=n------Size-----1.Z t ------Liquid depth............Yj2"-----_:Capacity_____�w___._ Disposal Field: Distance from nearest well---.- __.__Distance from foundation-----&—_______-Distance to-nearest lot line-___S_______ ] Number of lines--�----------------------------Length of each liWidth of trench-------,--- -v................ Type of filter material------I21y�__________Depth of filter material______ __..___Total length-------------��-:___------------ Seepage =_____-_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-------------------------------------- El Size: Diameter--------------------------- ----------Depth---- --------------------- -------------------------Liquid Capacity----------------------------gals. F?rivy: Distarce from nearest well-------------------------------------------------Distance from nearest building--------------------------------_---------- ❑ - Distance to nearest lot lire:-------- --------------------------_ ----------- - Remodelingand/or repairing (describe)---- ----- ------------------------------------------•----------------•-------------------------------------------------------------------•------------- --------------------•- --------------- -----------------•----------------------------------------------------------------------------------------------------------------------------------------• -•-----------=---- --• ,: -----------------------------------------------•------------------------------------...---------------------•-•------------------------------------•----------------------------------------------------•--------------------- -------------------------------------------------------•--------------•----------------------•---------------------------------------------------------------- -------------------------------------- ----------------------- I ---------------------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 regu ations of the San Joaquin Local Health District. (Signed)--------- ------------------ -- -------------------------------- ------------------------ ------------------------------------ ----(Owner and/or Contractor) Sy:----------------------:----------------------------------•--------------------------- --- ------------------------------------------(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 e/ �------------------------------------- DATE =/J Sf APPLICATION ACCEPTED BY------------------------------------------ -- REVIEWEDBY-------------------------------- -------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------ ----------------------------------------------------------------------------------. DATE------------------------------------------------------------ Alterations and/or recommendations--------------- ------------------- --------,----/--`-•------------------ - ----------- -- -------------------------------•--------------------•------------•-------------�J-�Lf '��fl��}--•------- `j `i --------/r!` -- ------.- i;=s'} ^�r --•--'-- ----•------------------------------ 1W . /� ----!__-- - ----------------------- --------- -------. ---- � e/?/ -------------- -------- ----------------------------•-•------------ ----- ---------- ------------------------------- ---------------------•----------------------------------------------- • Date---- ------------- -------------- FINAL INSPECTION BY:-------- '. --- 4 ------------------------ I - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West 001 Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California 1 E5-9-2M Revised W-2100 _