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FOR OFFICE U : -..----____ �- ---- -------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) Date issued -_--._.- This Permit Ex Ives 1 Year From Qate 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 . 549. JOB ADDRESS AND LOCATION--,------1 -- .. -------------------- .....----- Owner's Name---------- .------ � -•____ --------- Phone, ---!_ --- Address---- -------•-••••� `-... -------- �71 Contractor's Name----------------------------------------- -- ----------------------------_------------------------•----.._- Phone �- Installation will serve: Residence ff-_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: /---- Number of bedrooms - Number of baths __f---_ Lot size _14'el.-X,X1? �______________________ Water Supply: Public system Community system ❑ 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: (If yes,date_------------------) No ❑ New Construction: Yes ❑ No �HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Q Tank: Distance from nearest well-----------------Distance from foundation--------------------Material----------.------------.-----------------........ W110 No. of compartments--------------------------Size.-------------------------------Liquid depth--------------------------Capacity_...-•----------•------ P l eld: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- Number of knes-----------------------------------Length of each line----•-------------------------Width of trench-----•-------:-----------------_-_ Type of filter material_ ---_ ____---_-Depth of filter material___-___/__-___--_.__-Total length___________________________________�_____ Seepage t: Distance to nearest well____Distan; am undation_1__d---_------Distance to nearest lot line___S- ----. Number of pits------- Lining material- _____Size: Diameter___ . ______..___Dept h-------2_S_---________.._. Cesspool: Distance from nearest well_________________Distance from foundation--------------.-----Lining material-__________-__-____--__--.__---_--. ❑ Size: Diameter--------------------------------------Depth----------------------------•------------ ----------Liquid Capacity. .......--------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 11 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,pSelaws, and r les and regulations of the San Joaquin Local Health District. (Signed)------ --------- ------------------------ ' Owner and/or Contractor) . By: --- � (Title)------------r--- ----- (Plot plan, showing size of lot, location of system in lotion 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-------•------------•--------------------------------------•- AlIfdo s and/or recommendations:--------------------------------------------------•-••--•-----------------------------------••------------.......-----•-------...-----•----------------------- . v- b ----------------------------------------------------------------------------------------------- FINAL INSPECTION BY--- --- -- ----- -----Fa---• Date------- _ Alfa ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Wcll,California Manteca,California Tracy,California EH-9 REVI9EO 9.59 F.P.CO.2M 6-GO