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- APPLICATION FOR SANITATION PERMIT Permit No_ ---------_________-_ ` (Complete in Duplicate) �+ 6 �r7�CM+ ate 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, JOBADDRESS AND LOCATION--------_-------- ' �� ------------=----------------------------- ---------------------------------------------------------------- Owner's Name---------------------------------------------------------------------------------=---- - --------------------------------------- Phone------------------------------------ Address-------------------------------------------------------------------------------------------------—x----------------------------------------------------------------------------------------------------------- Contractor's Name---------------------------------------- --•--- Phone----------------------------------- --------------------------------------------------------------------------------------------- - Installation will serve: Residence ❑ Apartment House D4 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unifs: :2_ Number of bedrooms _- - Number of baths _ _ Lot size ----------------------______________________________________ Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table _31�f_ft. , Character of soil to a depth of 3 feet: Sand ❑~ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 2' No ❑ `. TYPE OF INSTALLATION AND SPECIFICATIONS: - 4- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material _______-_______-_______________________1771 -.t No. of com artments-------------------------Size--------------------- Liquid depth--------------------------Capacity Disposal 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------------------------------------------ ------- Distance from foundation___________________Distance to nearest lot line___________--___ Seepage Pit: Distance to nearest well---------------------- _ ❑ Number of pits----=-----------------Lining material ------------------------Size: Diameter------------------------Depth--------------------------- Cesspool•a Distance from nearest well-----`'_R_S_ Distance from foundation-----l0-___-___.Lining material------ Size: Diameter_____ -C -----------------De th---_---- --------------------------------------Liuid Capacity ------------------------gals.-' 1 t buildin � w Privy: Disfiance from nearest well__'- --------- --------- --------- _Distance from nearesg---- ❑ Distance to nearest lot line-------==-------------------------------------' --------------------------------------------------------------`------ -------------------- Remodeling and/or repairing (describe):--------------------y------------------------------------------------------------------------------------------------------------------------ ------------------------------------- -------------------------------------------------------------------------------------------------------------------------•---------------•--------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------=--------------------------------------------------------------- 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 rules and regulations of the San Joaquin Local Health District. (Signed) ---------------------------------------------------------------- -------------------------------------------------------------------(Owner and/or Contractor) ; By=-------- ---------------------------------------------------------------------------------------------------------------------- ----(Title)--------------------------------------------------------------- 1 (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 BUILDINGPERMIT ISSUED--------------------------------------------------------------- -------------------------------------- DATE------------------ ------------------------------------------ Alterationsand/or recommendations:----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------ ----------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- -------------------------------------- ---------------------- ----------------------------------- --------------------------------------------------------------'"------- FINALINSPECTION BY------- ------------=------------------------------------------- Date------------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Fiorfh "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California '- ES-4-2M 8.51 Revised W-2100 F