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APPLICATION FOR SANITATION PERMIT Permit No. ........ (Complete in Duplicate) -� M Date Issued Applica ion 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 LOCATION--------ai/o--�-------�-RAA�'-S------ -�!----------------------------------------------------------------------------- Owner's Name------ ---------- ----------------------------------------------- Phone------------------------------------ Address � ' ---------- ` Contractor's Name----------------4�� 4_ �! I a,- --------------------------------------------------------------------- Phone-,--7 U--,�------- Installation will serve: Residence IK Apartment House [I Commercial ❑ Trailer Court ❑ Motel ❑ Other / r Number of living units: _ _ Number of bedrooms �--- Number of baths _ ,__ Lot size ____ Ut_ ___�___--_ ________________________ Water Supply: Public system OQ Community system ❑ Private ❑ Depth to Water Table ---eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe .0 Hardpan t 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.) Septi Tank: Distance from nearest well_______________Distance from foundation--------------------Material----------------------------_--___----._________- No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Dispo 1-•Fie Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_._______-_-._... t Number of lines-----------------------------------Length of each line------------------------------Width of.trench----_----------------------------.- Type of filter:material------------ - ----- Depth of filter material------------------------Total length------------------------------------- �= Seepage Pit: Distance to nearest well---------40`-------Distance from foundation--.A-0.-------Distaa„e to nearest lot line_�4r_______ Number of pits___-_1--------------Lining material__�_�_tf_�.K_.Size: Diameter_____�h/_ -------Depth______-`_ ________---__. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__------____-----___-________________- ❑ Size: Diameter-------------------------------------Depth----------•--------------- ---------r--------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building_-____________________________-____-___.-. ❑ Distance to nearest lot line-----------------------------------------------------------------------------------------------------------------------.--------------------- Remodeling and/or repairing (describe)___________________ : ------ --- �_ tF_ _ 6 - -a ----------------------------------------------------- --------------------------------•---• ------------------------------------------------------------------------------------------------------------------- I I hereby certify that I have PXpared this application and that the work will be done in accordance with San Joaquin County Y ordinances, State an mule and regulations of the San Joaquin Local Health District. r (Signed) ...� -:.. ---------------- ----- ""-^----------------------------------------------------=------------------ ---Owner and/or Contractor) F By:------------------------------------------------------------------------------------------------------------------------------------(Title)------ -- -------- - --7----------------- (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-Q'-------------- ---------------------------------------------------------------------------- DATE_--'�-„--------------------------------------------------- REVIEWED BYDATE__ ----------------------- ------------------------------------------------------------=-------------- ------------------------- BUILDING PERMIT ISSUED-- -------------------------------- ------------------------------------- DATE-------- Alterations and/or•.recommendations---------- -------------------- ---------- ------------------------------------------------------------e-------------- ------------------------------------------------------------------------------------_----------------------------------------------------------------------------------------------•-------------- "?Q- --- 1 -•---------------------------------------------------------------------- ------------------------------------- --------------------------------------------.----------------------------------------------------------------- GG ✓ — FINAL INSPECTION BY---------------- ------------------------- ----------- -------- Date_..--------------=------��--�---- --------------------------------- � „ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C” Street i Stockton, California Lodi, California Manteca, California Tracy, California I ES-9-2M B-51 Revised W-2100 i r