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w APPLICATION FOR SANITATION PERMIT Permit _�� ( ` (Complete in Duplicate) Date Issue -_ ---_-..- -- ----- 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-Odrdinance No.x5_49 ��yy JOB ADDRESS AIai,D L CATI N-__�-.�-.__V - ---------•---- _______ ------------ --------•-----------------------------------•------------------------- Owner's e— 1__O- Q -----=- -, = ----- ------- - ------- -----•---------------------- - ------------------- ---------------- Phones " Address -----------------------•---------------------- -- ----------------•--------- --------------------•--------------------------------•--------------------------------- Contractor's Name-------------------------------- -------------------------------------------------- •-----------------------•-------------------------------- Phone------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 9ther ❑ e Number of living units:-_-�__ umber of bedrooms -_�---- Number of baths�of size _� "_�_. _________________________.--._-_ Water Supply: Pubiic 'system. Communify system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to_a�depth of 3 fee+:. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ I 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 de th--------------- -----Capacity �. Disposal Field: Distance from nearest well-----------------Distance from foundation--_-------.._---.-.Distance to nearest lot line--_-_------- W 171 Number of lines-----------------------------------Length of each hne------------------------------Width of trench---------------------- O Type of filter material---------------- -------Depth of filter material_-__---_.----__-'__----Total length-__.-----_.---__---__-----_.-------____-- F� 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-------------��0-.-------.--------_----Distance from nearest building__-----c-p______-_----.-._--.___-. Distanceto nearest lot line-Jo-------------------------------------------------------------------------------------------------------------- Remodeling --- ---------- ------- - - -------- Remodelingand/or repairing (describe)---------- --------------------------------------------•------------------------------------------------------------------------------- -----••--------------•-------------------•-----------------------•--------•---------------------------------•-------------...----------•----------------------------------•----•-••--------•------------------------ ---------------------•--------------------•-------------------------- -----•--••-•---------------------••-•--------------------------•------------------------------------------------------------------------------ --- ---------------------------------------------------- . ---------•-------------------------------------------------------------------------------------------------------------••--------------------------- I hereby certify that'l 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)---- � ----------------------------------------- ----------------------------------------------------------- --------------------_(Owner and/or Contractor) BY� -•• -A4lx (Title)-------------------------------------------------- ------ (Plot plan, showing size of lot, location of•sys�em�n relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By-.- .. -------------- -- DATE - REVIEWED BY_ ----- ---------- ------ = = DATE ---------------------------------------- BUILDING PERMIT ISSUED - -----------------------------------------------------------------------.-.._ DATE. Alterations and/or recommendations:--------------- • ------------------------ ---------- -----------------•----------------•---------------------•---------- ------------------------------------------------------.-------------------------------------------------------------------------------------------------------------------------------•-----------------------•--------------- - ------------ -------------------------- -------- •--------------------- ---- --------•----=---------------------- ------ b FINAL INSPECTION BY:------- -- ----------------- Date--- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street \.. Stockton, California Lodi,,California Manteca, California Tracy, California ES-9-2M io-52 Revised W-2100