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ti OLICATION FOR SANITATION PERMIT -Perm;f No. _ l d ...... (Cm`plein Duplicate) i Date Issued � 1 L R 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 ith Cou ty Ordinan e No. 54499{.] JOB ADDRESS AND LOC ION..._ \ - � Owner's Name----------------%< -------d --------- ----------------------- --- Phone------------------------ Address--------------- ----------------------------------------------------------------------------------------------------------------------- ' Contractors Name ------- ----- --- Phone------------------------------------ 1__ ___ Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other,9 Number of living units: -------- Number of bedrooms ________ Number of baths ------- Lot size _______________________________________________________-_ Water Supply: Public system 4 Community sysfem '❑ 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: 5 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest.well________Distance from foundation---16-'0-'*!-Material__ ��_____ _____________' No. of compartments---------- ----- - r quid d h---------- __Q`�__Capacity----_-1�_ � ;�i Dispos . re Field: Distance from near well_______--r___._Distance rom foundation_-------------------Distance to nearest lot line_________________ Number of lines____ ____ _ h- ^-�-Length of each line------------------------------ _ -Width of trench____ ___'Z �`__________ Type of filter material- �"�___- epth of filter material---------- length------------7-4 ____:___°'_.______ 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---------------------------gals;.gals.- Privy: Distance from nearest well------ ------------------------------------------Distance from nearest building______._______._________________________- ❑ 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, State laws, and rules and regulations of the San Joaquin Local Health District. l (Signed)-------------------------------------------------------------- ------------------------------------------------------------------------------ --------------------(Owner and/or Contractor) : 1 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 1 APPLICATION ACCEPTED BY---------------------- fi-- DATE------------•-- f�, ` - REVIEWED BY - DATE .. BUILDING PERMIT ISSUED------------------------------ - --------------------------------------------- DATE------------------------------------------------------------ Alteratige sf�and/or r ommenda ions:---------- -------------- _--• --------- -------------------------- r------------------------ ---- -------_-_--------•--- ----------- - ----------------------�---�-------- =� ----- ----------------------------------------- ' ----------------- --------- - - ----- -- ----------------•----- � �� '� ------------ - J ------ --------------- ------------------------- ---- - - ' FINAL INSPECTION BY_______________ ____ ! y.---=��, ------- Date (- _ SAN JOAQUIN LOCAL HEALTH DISTRICT y 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 8-51 Revised W-2100