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APPLICATION FOR SANITATION PERMIT e) Aermit No. (Complete in Duplicate) ' r ' t I :,gdh L, Application is hereby made to the San Joaquin 1► jJ q Local Health District for a permit to construct and install th w herein This application is made in compliance with County Ordinance No. 549` a work herein described. JOB ADDRESS AND LOCA710 Owner's Name------- � - 0------- = ----- -- Address " _—e- - -..:_ Phone------------------------------------ ---------------------------------------- ontractor s Name___ < ----------------------------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial 0 Trailer Court ❑ ' Mote! _ ❑ Other ❑ Number of living units: _-�._ Number of bedrooms -------- Number of baths -----.__ Lot size ---- Water Supply: Public system ❑ Community system ❑ Private [] "Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ Previous Application Made: Yes ❑i No ;E New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: + 1 k j (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----------------"Distance from foundation--------- -----4 Material -------------------•-------- ❑ No. of compartments Size --------------------Liquid depth - Capacity."" Disposal Field: Distance from nearest weEl - "._._Distance from foundline' ation-----------------.--Distance to nearest lot -----_----..----" ❑ Number of lines -------------- -------------------Length of each line------------------------------Width of trench----------------------- Type of filter material----"_----------- Depth of filter material-----------_-----------Total length----------- """--" Seepage Pit: Distance to nearest well---------------------- 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----I---------------------------- ---Depth----------------------------------- ------ l. Liquid CapacitY----------------------------gals.i Privy- Distance from nearest yell----/me----'- d?�^---" _-"Distance from nearest building Distance to nearest lot line---------------- -- / g" ------------- ---------,4 �0 -------------------------------------------- Remodeling and/or repairing (describe)------------------------- ' ----•---"--- -------- •---------------------- -----------------------------------------•-•------------------------------•------------- + y ---------------------------•--••---------------------- -----------------------------------------•------------------------------------------------------------------------ ------- ----- ------ ----- ---- - ----- - - •- ---- -- ----------------- ----- ------ - - ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules ands regulations of the San Joaquin Local Health District. (Signed)_ V �� I -----------------------(Owner and/or Contractor) (Plot By:--------••-----------------------------------------'------------------------- ------------------------------------------------------Titie --------------------------------------------------------- _ ___ _ ( of plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --_ --c- d REVIEWED BY - -------DATE---------._r --------------------------------- - DATE -------------------- UILDING PERMIT ISSUED---------- -------`------ ------------------ -----•--- --------------- - ---------- Alterations and/or recommendations:---____-- `"-."y"" - -- : �' ' ; A QATE"-------------------------- ----- f ---- ---------------------------------------- I - .- --------------------------=----------------------------------------- - .•_---------•--------•---.-..-.--- -------------------------------------•----------- """_ -""" FINAL INSPECTION BY ______•__"" ---------=`--•---------=------ Date--- - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street k 6300 West Oak Street * 132 S—.% ycamore Street Stockfon, California - 814 North "C" Streef M Lodi, California anteoa, California Tracy, California E5-9-2M 10-52 Revised W-2100