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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued Z1_ ---Y_jsf-113 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 wit County Ordinance No. 549. lk JOB ADDRESS AI`4D,-LO9ATI00----------- ----- ---------- f - --- ---------- --------------- ----------------------------------------------------------------- Phon' Owner's Name---- 4� ------------------------------------------ ------ ---------- -------------------- Address--------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name---- ....... ----------------------------- Phone House Residence H Apartment HosE] Cl Installation will serve: ommerciaD Trailer Court ❑ Motel El Other e Number of living units: ... Number of bedrooms NumbVer - baths _;„I_ Lot size Water Supply: Public system E] Community system E] Private ---------------------------- Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand rEl Gravel [:] Sandy Loam Clay Loam [;17clay El Adobe El Hardpan El Previous Application Made: Yes El No F� New Construction: Yes 2' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet Septi ank: Distance from nearest well___. _____Distance J�Drn foundalio--------------- ---------------------------------- Liquid dept.---------- No. of compartm enfs--------- -- ------- acify-------- ------------- Disposa cl�_ - . I ---------Cap Field: Distance from nearest wpll-- 92 D�stance from foundation-- � Z4--------Distance to nearest 1pt I I Number of lines____________,_________ � I �_ ength of each line-,-.- Width of trench----- ---------- ------ ---- ----?--------------- Type of filter of filter material------L-f-'.______Total length___-_______ _C�- Y - --------------- - IL Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________Distance to nearest lot line 0 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______,________-___________-------------------Distance from nearest building__-_____--.______- --_-__-- ---------Distance to nearest lot I;ne --------------------------- Remodelingand/or repairing (describe)----------------------------- -I--------------------------------------------------------------------------------------------------------I------------I----------------- -------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------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 I ws, and rules and regulations of the San Joaquin Local Health District. (Signed)-. -=------=-'-----------------------------1------•--------------------------------------------------------------------- -----(Owner and/or Contractor) By:------------------------------------- --------------------------------------------------------------------------------------------(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 APPLICATION ACCEPTED BY__,_ � --------------------- DATE----REVIEWED BY ------- ---------------------------------------- ------------------------- ----------- -------- --------------•---------------------------------------- DATE-r--... BUILDING PERMIT ISSUED ------------------------------------------ ------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:__________.____-_---____ ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------- ------------------------------------------ --------------------------------- ------I-------------------------------------I---------------------------------------------------- --------------------------------------- --------------------------------- ----------------------- ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:-.. ---------- ------------------------------ ---- Date---, -------/----------- --- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street f32 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100