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APPLICATION FOR SANITATION PERMIT Permit No. __ _ __ (Complete in Duplicate) r ~� ff ` 3 Date Issued ! �/-S' . - 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 Cunty rdinancq No. 549. ff JOB ADDRESS MID LOCA ON_, -t = - ------------------------------------------•------ -- - -- - ------------------------------------ Owner's Name. ------------------- Phone-Z----- Address --- ---- -- ---------- --- = -'-- ----- -------- Contractor's .Name-- ------- ------- -- ---- - ---•------------------------------------ ------------------- ------------------------------------------- Phone------------------------ ------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 7 Number of bedrooms -_ Number of baths _Z_ Lot size ------------------------------------------------------------ "Water Supply: Public system [Community system ❑ 'Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet Sand E] Gravel Sandy Loam Clay Loam [Clay ❑ ❑Adobe Hardpan E]Previous Application Made: Yes 7o E] New Construction: Yes [(No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if Public s wer is available within 200 feet.) f Septic 'ank: Distance from nearest well _ ___ _____-_ -istan from pund pn---1_---------.Mater' I_f ______ _________ [ No. of compartments Size__ x_�_ _ Li Liquid de th__--____. -_ p 9 i? -------Capacity.-12,P-D--- Disposal Field: Distance from nearest well--------------___.Distance from foundation--------------------Distance to nearest lot line_____________--- Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material--------------------------Depth of filter material---.-------------------Total length_______-_-________-__________-.--_-___---_ Se pa a Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--_______________ Number of pits_-------------------Lining material----------------- ----Size: Diameter------------.......----Depth--------------------------------- Cess ol: Distance from nearest well-------'_---_-__-Distance from foundation+__________________ Lining material_____---------_-------_-____-_____-_ ❑ Size: Diameter-------- Depth----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El ________-__-__________- _--------___--.❑ Distance to nearest-lot line------ - --------------- -----------------------•------------------------------------------------------------------------------------------- Re0 �.-------_-_-- �.(�!� ---------------------------------------------------------------------••-------------------------------------------------------------------------------------------------- --------•------------------------------------------ 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 a regulations f the San Joaquin Local Health District. �J � r (Signed) ff -- -- --------------------------------------------------------------------------------------- ------(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 APPLICATION ACCEPTED BY--- -------------------------------------------------------------------- --------------------- DATE-------------------------- REVIEWED BY------------------------------- - DATE__ ----------------- BUILDING PERMIT ISSUED------ •------- DATE--------w------ Alterations and/or recommendations--------------------------------------- -------- -- ----------------------------•-----------------------•----------------------------- ---------- -------------------------------------------------------------------------- ---I-----------------------=---------------------------- -------------------•-----------------------------------------•----- -------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ---------------------------------------- ------------------------- ------- --------------------------------------------------- ----------------- FINAL INSPECTION BY:. � ----- ------------ Date--- ------- ---h -'' 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 k