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APPLICATION FOR SANITATION PERMIT Permit No.�-a'- ' (Complete in Duplicate) y i♦< y Date Issued . --------_- � 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 Ordinance No. 549. JOB ADDRESS AND LOCATIO ,-- - - - I----------------------------------------------------------------------------------- ------ Owner's Name-------- --- ------------------ ---------------------------------------------------- -------------- Phone--15�4-- 1 ------- Address------------------ .. --- -- - --- ----------- -----------------------------------------------------------------------------------•---------------------------------- Contractor's Name--------------------------------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence lVd Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /_____ Number of bedrooms I---- Number of baths Lot size ------ �_�,�'__�,�__�'________--------- Water Supply: Public system 0 Community system 0 Private ❑ Depth to Water Table4_d__ ft. Character of soil to.a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe.V Hardpan E] Previous Application.Made: Yes ❑ No x New Construction: Yes ❑ No TYPEOF INSTALLATION AND SPECIFICATIONS- (No PECIFICATIONS: ( r r P P_________ Distance from foundation__ 0- Material----rL`'i�"�/___________- Septic Tank: Distance from nearest well__ � �_______________ No septic tank or cesspool permitted i public sewer is available within feet.) I No. of compartments--------I Size__ " --- ---Liquid depth__ _ ' :-----Capacity----- - -- Disposal Field: Distance from nearest well_ ' _.Distance from foundati n___Z [_________Distance to nearest lot lin ---t._-____- Number of lines___________ _ Length of each line-----�ie,__�_ _____________Width of trench____2, - --------------- �h Type of filter material ___ Depth of filter material__�7�.o____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------------------------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--'-. ------------------------ _________ __________Di€stance from nearest building------------------------------------------ 171 Distance to nearest lot line---------- -------------------------------------------------------------------------------•------------------------------------------------ Remodelingand/or repairing describej:---------------------- ----------------------------------------------------------------------•---------------------------------------------------------• 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).. _ ` � ------- ---------------------------------------------------(Owner and/or Contractor) E g� (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 r APPLICATION ACCEPTED BY-------------- ------------- ---------------------------------------------------------------- DATE- REVIEWEDBY----------------------------------- ----- - - - - -------------------------------- ----------------------------------- DATE-- '.� e '" '.�W_•�--_ BUILDINGPERMIT ISSUED------------------ - ---------------------------------------•-----------------------------:-------- DATE--------------------------------------------------------- ------ -------- r Alterations and/or recommendations:__-.___ ------------------------- -----------------_...----------------------------------------•- --•----------------- ----------••---------------------------------•------------------------------------------ ----------------------------------- --------------- ------ - ----------------------------------------------------------------------------------------------------------------------------------------------- i FINAL INSPECTION BY:.-- - ---------------------------------- Date--------------0 ,f �Q 7E=---•----------------- 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 8-51 Revised W-2100