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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) ,/1�1 I I 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 ✓ ---------------- ------------ _Owner's Name... ---------------- --- y Address-------- ........... ----1----- Contractor's Name--------- ------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_-L Number of bedrooms At. Number of baths __/_.. Lot size ...../n_P_-x.. ./_�� ______________________-_ Water Supply: Public system ❑ Community system ❑ Private Z-obepth 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: Yesto ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance from nearest welly _*______Distance from foundation---rP-----------Miiter•al_%�_ _____.. No. of compartments______`_________________Size_--`9_iU Xf_____._._--Liquid depth_._:-_ -_________Capacity___XG__ ------ Disposal ___. Disposal Field: Distance from nearest well_ ___._Distance from'foundaton _�_-__�__.Distance to nearest lot line_________________ Number of lines........:- �_______jj_ Length of each line-_S__��r._....Width of trench-_- ______________________ Type of filter mate ria ________Depth of filter material---s�-___________-_Total length----- ......................... Seepage Pit: Distance to nearest well------_---------------Distance from foundation....................Distance to nearest lot line----____-___-__-. ❑ Number of pits______________________Lining material-----------------------Size: Diameter------------------------Depth_-_-_-___-._-_____--_____________ Cesspool: Distance from nearest well-----------------Distance from foundation-_------------------Lining material---------._____________-_-____-__-_--. ❑ Size: Diameter------ ------------------- ----------Depth-----------•------------------------------------.--Liquid Capacity----------------------------gal Privy- Distance from nearest well--------_----------------------------------------Distance 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 rules and regulations of the San Joaquin Local Health District. (Signed) �__ ---- ---------------------------------------------------------------------------------=--- ------(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 APPLICATIONACCEPTED BY--------------- ------------------------------------------------------------------------------ DATE-------------------------- --------------------------- REVIEWED BY---------------------------------------- DATE ' BUILDINGPERMIT ISSUED-------•-----��------------------------------------------------------------- DATE--=--------------------------------------------------------- Alterationsand/or recommendations------------------------------ -----------------_-_ ----------•----------------------------------------------------------------------...-------------- ---•-----•----------------•-....-------•----------------••---------•------------. ----------------------•------------•---------------•--•----•--------•----------•--------•--••-------••---•--•------•------•-•-••------------ ----------------------------------------------------------------------- -------------------------------------------------------------- -------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------ ---------------------- ----------------•-------------------------------- -------------------------- --------------------------------------------------------------------------------------------........ FINAL INSPECTION BY:------- Date_------- `Sr �/i`�r.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 10-52 Revised W-2100