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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ---- Application ---Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst II the work herein described. This application is made in compliance with Count rdinance No. 549. �r JOB ADDRESS AND LOCATIO __________ _____ __ Owner's f ` Name--------------- Phone--------------------- Address..--------------------------��----------•-------------------.-- ------------------- -------------------------------------------------- Contractor's Name--------- ----• Phone Installation will serve: Residence U__7�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I l _ Number of living units: __/____ Number of bedrooms _-2---Nijmber of baths J_- Lot size ------T,Dr-0_- ------ ____------- _�V Water Supply: Public system E] Community system E] Private epth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe44--44ardpan ❑ �` Previous Application Made: Yes o ❑ New Construction: Yes o❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material__________________------------------------_---- ❑ No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity----------------------- DVI I Field: Distance from nearest well---/_ istance from foundation__/`4__ istance to nearest lot line____"------- Number of lines------------/------------y�_____Length of each,line----------Lrt_C� �_j_j___-Width of trench__________�_____________________ Type of filter- material �1 -------Depth of filter material_________ _______Total length-----------16-----Q--------------------- 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. Privy: Distance from nearest well------------------------------ -----------Distance from nearest--building----------------------------------------- ElDistance 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) -- ----- -----------------L---------------------------------------------------------------- Owner and/or Contractor -----------------------------------------------------(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----- - - --------- ----- ---��--------------------------- BUILDINGPERMIT ISSUED-------•--------------------------------------------------------------------------------------------- DATE------------------------ -- - - Alterations and/or recommendations---------------------------------- ------------------------------------------------------------------------------------------------------•-------------------- --------------------------------------------------------------------- --------- -------------------------------------------------------------------------------•-•----------------------------------------•-------..-- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- FINAL. INSPECTION BY: ~r��--------------------------------- Date ` /- - /r rr 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 8-51 Revised W-2100