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,.\ APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued V Application is hereby made to the San Joaquin Local Health District for a permit it onstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. � JOB ADDRESS AND LO ON -------------------------- —-:-- -- �' �C�[ Phone '2 sU Owner s Name._11.._____ -- --- --- ¢------------- ••---------- -------------------------------------------------•--------------------------------- Address--- •---� ----------- aOne ---- --- ---------- -- Contractor's Name_. `' � � - --------------------------------------=•-------------------- - Installation will serve: Residence Apartment ouse�❑' Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms E_ Number of baths _ ___ Lot sae - �dQ--------- Water Supply': Public system Community system..[]' 'Private ❑ I Depth to Water Table-6 ft. 4 ` Character of soil to a depth of 3..ie_et: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑',Clay ❑ Adobe Hardpan 1 Previous Application Made: Yes ❑ No W New Con strucfion:.,Yes [I ;Noo^ f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within-200 feet.) pti�Tjank: Distance from nearest well-________________Distance from foundation_-___-_.____._____.Material____._._---_-_____________-._.____..._-_____._. No. of compartments------ ---------------- --Size------•------------------------Liquid depth--------------------------Capacity----------------------- DispoDistance from nearest weli__.__...________Dlstance from foundation-------------_------Distance to nearest lot line_---__.______-_._ ❑ Number of lines---•-------•-----------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length---------------------------.-------------- Seepage Pit: Distance to nearesf'well_.___________--------Distance from foundation-------------.------Distance to nearest lot Ii ne-----..__________ ❑ size: Diameter----•-------• ---Depth---------------=-------- Number of pits.---- I--------------Lining.material---------------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining mater --- _____.__.._. ❑ Size: Diameter------- ------------ -------------Depth----------------------------- Liquid CaptY-.:_ _ s_ gals.- • ' ` `.— nearest well--,. ___-_____-._Distance from neares+ building 'Privy: Q Distance from nearest well-6-------------- 9 --------- ------------ ❑ Distance to nearest.lot line_ -- ---------- ---- ---------------------- - ----------------------------- mode nd/or re air in describe 'I �� _ -- -- - ---•-- ------ ----------------, --------- ----------------------------------------------------------- --..... --------------------- ------- - ------------ - I hereby certify hat I have prepared this application and at the work will be done in accordance with San Joaquin County ordinances, State laws, rules an r ulations of th San Joaquin Local Health District. 1 Owner and/or Contractor) - --------- - (Signed) l�� --- ------ [Ti+le)- [Plot plan, showing size of o , locrtion o system in relation to wells, buildings, etc., can be pl don reverse�ide [ t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYc�.. -- ------- ------------------------------- -------------------- DATE_ f REVIEWEDBY------------------------------ =-----€-----------------------------_-------------- --------------------- DATE BUILDING PERMIT ISSUED------------ ---- -- DATE Alterations and/or recommendations--------------- ------------ --------=---------- -------------------------- i ---------------------- - . . r -- ---t--------- -------------------------------•--------------------- ----------------------- ------- --------------- ----- -- --------- ------------ -- --- -•--------- FINAL INSPECTION BY ------------ ------------------------ Date - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South132 Sycamore Street 814 North "C" Street American Street 300 West Oak Street Y Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100