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APPLICATION FOR SANITATION PERMIT Permit No. ...... s 1 . ` (Complete in Duplicate) Q \, l Date Issued ... ......1 pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. is application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND CATION. //�------ _ ---------------------------------------------------------------- -- Owner's Name --------------------------- _ Phone---___�GI_---�� _ Addres = =�- = Z---------------- ----------------------------------•--------------------------------- ------------------- Contractor's Name------------- / :�-- -------------............................................................ Installation will serve: Residence Apartment Ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..f_''umber of bedrooms ./__ Number of baths ../_ Lot sizeIre Water Supply: Public system F-1Communitysystem E] Private Depth to Water Table - f �� Character of soil to a depth of 3 feet: Sand E] Gravel F1 Sandy Loam E] Clay Loam El Clay Adob 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.) Septic Tank: Distance from,,nearest well____�5D.....Distance from foundation__,1�........Material ______________ No of, comparfinents___�-------------- Liquid depth,r`..?G ---__-__.Cap Disposal Field: Distan4,fioKAP*l well-________._,._Distance from foundation--------------------Distance to nearest` El Number of lines. _________________ ______ Length of each line--__-___-_____._-___.-___-.Width of trench TApe of filter material___ __ _____________Depth of filter material-----------------------Total length-------------f.__. -__.............. Seeps a Pit: Distance to nearest_w®ll - '"------Distancef�m^fo dation__, Distance to nearee lot line _._..z�_..� Number of pits..---- -------------Lining materi Size: Diameter Dept h ,t Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material-------------------------________--. ❑ Size: Diameter-------------- •-------------Depth------•-----------•--------------------------------Liquid Capacity-------------------_........ gals. Privy: Distance from nearest well------------------------------------------------- from nearest building_.-__-__--____.-________-•--_________-_. [❑ Distance to nearest lot line---------------------------------------------------------------------- ---------•-------------------------------------------•---------------- Remodelingand/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, State laws, and les and regul ' s of the San Joaquin Local Health District. (Signed)-------- - f- ;,r--- -- == �Owner/aq4jor Contractor) By:---- "`-`-- - - - r (Plot plan, showing siz of lot, Iotaoi4 n ofsystemin relation to wells, buildings, etc., can be plaEa on reverse si FOR DEP MENT USE ONLY APPLICATION ACCEPTED BY------------------- --(,elf--------------------•---•------................... DATE---- - � ------ REVIEWEDBY----------------------------------------------------------------------------------------------------•----------------------• DATE------------------- ------------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------............• ------ DATE------------------------------------------................ Alterations and/or recommendations:--•---------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------........................................ ----------------------------------------------------------------........................................................................... .............•------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----- --------------------•-------------- ------------------------------------------•---------------------------------•---••---------- ---•-----------------------------------------------------------------------•---------------- FINAL INSPECTION BY:----- � 1------------------------------- Date--------- ---------------- 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 0-52 Revised W-2100