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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) I S� Date Issued krb5 Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein desed. This application is made in compliance with County Qrdinance No. 549. A JOB ADDRESS AN OCATI ----- . . ��"�'=--------- ------------- --- r Owner's Name- --- ----- ---- ------ ---- --------------------- ------------------------------------------- ---.-- Phone------------------------------------ Address-------- ---•-------------------------------Address--•------- __; --•--------- - -- ------ -------------------------------- Contractor's Name------------ Phone----- Installation will serve: Residence ❑ artment House ❑ Commercial ❑ Trailer Court ❑I��Motel�❑ Other Number of living units: `V Number of bedrooms __-le Number of baths ---L. Lot size _�>-3�Y'- A.-Cwt-of-Re Water Supply: Public system ❑ Community system ❑ Private Ok Depth to Water Table !�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam x Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 9,New Construction: Yes 0\No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pudic sewer is available within 200 feet. Tank: Distance from nearest well_ ___.0--l'Distance from foundation-- _______._.Mat rial____ ""_--- Septic _____ _.. No. of compartments-----------�,.___._.__Size_ �_ __r_uiquidlldepth__..___ ... .__...._.Capacity__ _ i5--------- Di ____. Disposal Field: Distance from nearest well__/ZV_�Distance from foundation_-.-_[__ '~___Distance to nearest lot li e_It__�t.�_____ - Number of lines_________ -------------- � ------ --Length of each line------I-�--C�-----------Width of trench----R-�- -- -------------- Type ----- •-_ Type of filter mate ria IST -Depth of filter material____�___ ----------Total -.._______________._____ 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---------------------------v-----------------r----------------------- -------------------------------'-------------•-•-------------------- ,. Remodeling and/or repairing (describe)-__ ._ __ _._ ------------ - -------------------------------•----------•----•---•---------------•------------------------------------------------------------------------------------------ ------------------------ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Staf laws, and:rules and regulations of the San Joaquin Local Health District. ----- Owner and/or Contractor C� (Signed) - -------- . ( I `tJ 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 APPLICATIONACCEPTED BY------------- - ---------------------------------------------------------------------------------- DATE-----------------------------------------•-•---------------- ----------------------------- BUILDING ----------- REVIEWED BY--------------------------------------------- -- -- DATE------- o`�_ _ BUILDING PERMIT ISSUED----------------------------------- ------------- ------------------- DATE.------- -_------ - - - Alterations and/or recommendations--------------- ------ --- -- ----------------------------------------•---•-------•------------------------------•--------------- ------- --------- ------ --------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- -------------- z ------------------------------------ - ----- ---------------------- - -------------------------- ----------------------- ---------- FINAL INSPECTION BY--- ---------------- ------ 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 ES-9-2M Revisod W-2100