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APPLICATION FOR SANITATION PERMIT Permit No.,�_-.�__ (Complete in Duplicate) y yQ Date Issued r�J Application is hereby made t 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 LOCATION----------- _ - Owner's Name------ -. ------- _.. ------------------------------------------------------------------------- Phone------------------------------------ Address------- ------------------------ - Address------- ----`-`--- ------------------ 0--•----------------------------------- ------•---•--------------------------------------------------------•--- Contractor's Name------• ------------------------------------------- -- Phone---------------------------------- Installation will serve: Residence 600 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 ❑ PrivateDepth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe , Hardpan E]Previous Application Made: Yes ❑ No/K New Construction: Yes X No F] ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welll,1,0__k_----Distan from / foundation1.4__`_________. izex Liquid de th-. Capacity--Yd.--ti---------- X Material_ __ -__._Ca_p_ac_i_t.y____ _ h , No, of compartments________ _______ ___S ___ Disposal Field: Distance from nearest well_/4_R_......Distance from foundation___*__-._.Distance to nearest lot line_ ----_--____- Number of lines_______I_________-_____]] Length of each line__4�c4__'.I__________-Width of trench----_��r4 Type of filter material-_ 4____._____Depth of filter material_19_______________Total length------/__---'"---___-_______________.___ gF Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____________---__ I ❑ Number of pits----------------------Lining material-------------.---------Size: Diameter-------------------------Depth--_----------------.-----------__ 1 Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-----------------------------..._____- ❑ Size: Diameter------------------------------ -------Depth----------------------------------------------------Liquid Capacity----------------------------gals: 1 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------- ❑ Distance to nearest lot. line----- ------------------------------------------------------------------------------------------------------------------ ----- ------------ Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------. ...------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------- i 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 regulations of the San Joaquin Local Health District. (Signed)____-- ---------------_---�Ioloca;i - ---------------- (Owner and/or Contractor) - --------- ------------------------------------------- BY - - - - - (Title)---------------------------------------------------------------- (Plot plaril showin on of systen4*'in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY—------------- ��_._4�_�� ---- ------------- DATE-__.-- . ------------------ REVIEWED BY---------------------------------- :z..-_:-1^1 --- ---- - ---------- DATE BUILDING PERMIT ISSUED----------- ------------ - DATE------------------------------------------------------------- Alterationsand/or recommendations-------------------- ----------- •- -- ---------------------------------------------------- -------- - � ---- ------------- ----- ;�{--- ----'"' � ` `Ir- ` . ' - --------------- ----- ------ --------------------------- :' ---- - --------------------------------- FINAL INSPECTION BY: -- -- --- ----------------------- Date------- - ---------------------- r SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California l ES---9----2M 8-51 Revised W-2100