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APPLICATION FOR SANITATION PERMIT Permit No. Y9-7-�---- �/— [Complete in Duplicate) u6' Y Date issued ----YV - ----�------- Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. i This application is made in compliance h_C y Ordinance No. 549. JOB ADDRESS AND LOCATION -''-�-----�--------------- �� '�' ----------------------------- Owner's Name----------�1_ --------------------------------------------- Phone------'-- '`----------------- , I f ---- -- --------------- Contractor's Name--------------------------------- ----, . ---------------------- -------------- Phone-------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms ________ Number of baths -------- Lot size _________________________________________________________-_ Water Supply: Public system ❑ 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 ❑ 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-----------------Distance from foundation--------------------Material---------------._________---_________,__.______- ❑ No. of compartments----------- -------------Size----------- --------------------Liquid depth-----------------.---------Capacity----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_______________. ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to neares}•well----------------------Distance from foundation--------------------Distance to nearest lot line------------------ F1 Number of_pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----------------- r "a Cessr I: + Distance from nearest well_________________Distance from foundation______.__„________. Lining material---------------------------_._.------- k,. Size: Diameter--------------------------------------Depth------------------------------_---------------------Liquid Capacity----------------------------gals. I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 4 ❑ Distance to nearest 4ot line--- ------------------------------------------------------------------------------------------------------------- Rem d,.. eling and/or repairing .(describe): r`/ � ----- --- -- ------ ------ --- -------- --- _ -------- --------------------------------------------------------------------------------------------------------d-------------------------------------------------------------------------------------------- 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)_ _0-1_. ----------------------•-----------------------------------------------------------------------------------(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--------: ------------------- REVIEWED BY------------- ----------. DATE------------•--f �---`---- ---------------- ---------------------------- r BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------ ,------------------------------------=--- Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------ --- ° ----------------------•--------------------------- ------------------------------------------------------------------------------------------------------------------------------------- -------------------•-------------------••--------------------------------------------------------------------------------------------------------------------------------------------------------- f ______________________ -------------------------------------------------------- U _____________._________________-__.-_-_,____-_____ 4 FINAL INSPECTION BY:------------------- -----------------•---------------4� Date ` t . ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak S+roa+ 132 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100