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APPLICATION FOR SANITATION PERMIT Permit No. ... ............... z4 7,10 (Complete in Duplicate) `,J 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 LOCATION....... I_. ------- Owner's Name------------- ------S ------------------------------------- ------------------------------------------- Phone----- ----------------------- Address................ ------------------------------------------•... Contractor's Name !1 ------------------_-------------------------------------- --------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l__-_ Number of bedrooms -------- Number of baths -------- Lot size ----________________________________________________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ 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.) t' Distance from nearest well_________________Distance from foundation--------------------Material---------------------------------------.--------- lo. of compartments---------- ---------- ----Size-------------------------------Liquid depth--------------------------Capacity-----------✓------ Dispo al Field: Distance from nearest well__. _ _#%,,A,Distance from foundation Distance to nearest lot I' Number of lines_...._.Q"M, _-__ th of each line______ ------------Width of trench__ Type of filter material. ter material.__ ._ --------Total length_______ �!c -- ------------------ Seepage Pit: Distance to nearest well-----___ ------------Distance rom foundation__--_____-.__-__-_-.Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------.-----Depth--------------------------------- �3 Cesspool: Distance from nearest well-----------------Distance from foundation_-----------------Lining material___._------------------------------------- �1 ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. l Privy: Distance from nearest well------------------------------------------------- from nearest building-____-___-__.-__-_--.-----____--.__--._. r\ ❑ Distance to nearest lot line-------------------------------------------------------- ------------------------------------------- -- - --------------------- 4)pW.0A-------.................... Remodeling /or repairing (describe):---- 440-----• •---• --- -- ----- --- ' --------------------------------------------------------------------------------------------------------------- --------------_---- ---------------------------•------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St I and s and regulatio of the San Joaquin Local Health District. (Signed)----- A ---------------------- ------(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----- - REVIEWEDBY-----------------------------•----- --------- ------------_--------------------•------------------------------- DATE...----------"l- BUILDING PERMIT ISSUED------------------ ------ -- -------------------------.--------...._.....------------. DATE------- --------- t - ``rr --------------------- Alterations and/or recommendations:.................... ----------------------------------------------------------------------- .................4 ---------•--------•----------------------------------------------------------------------------------- ----------------•------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- -------- --------- -------------------------------------------------- -----------------------------------------•------------------•--- ( , FINAL INSPECTION BY:.-------`�A'�-==-�J- ------------------------------ Date------`�--�,-----r_---f ---- ----�------ 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.-9-21vl 10-52 Revised W-2100