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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ell Date Issued ...........r-' - 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 o. 54 JOB ADDRESS;ANLOCATION ----- --- ----------- -------------- Owner's Name ---------------------------- -------------------------------------------- Phone............................. Address................4 •-•-----••-•-----•---•----------•--------------------•---•-----•------••-•....--------•--•••-------•--------------............------......------... / Contractor's Name-----6 _�,�------------------ .--------.--_-- Phon .�J__'- i®_�J'_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-/____ Number of bedrooms .___—Number of baths 4--- Lot size---,T__�__ ....0/3.......................... Water Supply: Public system ( munity system ❑ Private ❑ Depth to Water Table dO ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe pen ❑ Previous Application Made: Yes ❑ No [§ _ew Construction: Yes ❑ No TYPE OF OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well-----------------Distance from foundation....................Material-_-____________-__-.________________-._-_-__..... No. of compartments--------------------------Size................................Liquid depth--------------------------Capacity----------------------- isposal Field: Distance from nearest well-----------------Distance 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 nearest well----------------------Distance forrt foundation___.,_._._.f_-.Distanceto nearest lot line > Number of pits----1---------------Lining material.-ff__C -�...,-.--.Size: Diameter._.... _--Depth-----21-0_________________ 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_-____-__-.__-________•_--------_.--___-_. 4v, ❑ Distance to nearest lot line----------------------------------------------------------------------- --------------------------------------------------------------------- Remodeling and/or repairing (describe)-+--- - --------- - --------- ---�• ••--•--• ---------•-•--- ---•--. ------•---------•------•----------•--------•-•-------- -- --------------------------------------------------------------------------------__ ----------------_-�-------------------------------- ---------------------------------------------------------------------------------------------•----------------------------------------------------------•-•---•---------•------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a laws, d rules nd regula ' ns of the San oaquin Local Health Dis rich (Signed)------... --- -1 - --- -- ----- - --- - - ----- ---- ----- --•-- ---( Contractor) By:--------- . . --•--•--- •.- .� - ------------ (Title)- = ------------------------------------ (Plot plan, showing size of to , 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..... .._-• ----- ...................................... BUILDING PERMIT ISSUED _ - DATE ............ Alterations and/or recommendations-------------------------- --- .__...._ ..............................._..._......_ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------...........................................•---•- --------••-----•------------••••--••----•------------------------ ---------------------------------------------------•--•--------------------------------------------------------------------------------------- ------------------------------------------------•----•---------------------_----_-.----------------------------------.--------.- -----------.-------------------------------------------.------------------------------ ---------------------------------------------------------------------------------- ------------ ----------------------------------------------------------------------------------•----------•-------------------------------- `� - � =s FINAL INSPECTION BY:--- �-------- ----------- --------- Date---- 3.....: ------------------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; ' Revised W-2100