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vim✓ APPLICATION FOR SANITATION PERMIT Permit No. _____ ---- 1v (Complete in Duplicate) Date lss _ Applicaion 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 Ordin ce No. 549. JOB ADDRESS AND OCATI N _______L__- _ -__ .� ------ ---- ---------•---------- ------------------------------------------------------ -- ..._. j_ Owner's Name---------41-11----- _ --------- -------- Phone__ v ..... Address-----------------------� _----------------------------------------------•----.....--••--------------- ----------------------- Contractor's Name------------- -------------•------------------ .r---------------------------------------•-----•------------------ Phone-- " Q. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.___ Number of bedrooms _ _ Number of baths J___ Lot size ___uu - ------- ___C_ �_____________________ Water Supply: Public system 1��Community system El Private E] Depth to Water Table -7-0- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No V----New Construction: Yes ❑ No 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----------------------- Disposal Field- Distance from nearest well_________________Distance from foundation-----.--------------Distance to nearest lot line----------------- ❑� Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------.--------- Type of filfer material-------------------------Depth of filter material----------------------Total length___-____________________-_______________. r Seepage Pit: Distance to nearest ' 11 ----Distance from oun t:on____� -.Distance a to nearest lot liner- Number of pits--------__________Lining material___Li__�S�ize: Diameter____, _-___.....Depth_______________________ Cesspool: Distance from nearest well-----------------Distance from foundation___-----------------Lining material-------------------------------------- 171 - Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest yell--------- --------------------------------------Distance from nearest building-------------------------_._.----___-_. ❑ Distance to nearest lot lie----------- ----- ---------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------ !i---'"'1"--� ----- --- , ------------------•------------------ ---------------t----•------------------------------------------------------------------------------------------------•---------------••---- 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, an rules and regulations of the San Joaquin Local Health District. (Signed)----- ---------------- r e `'`r ---------- and/or Contractor) BY:------------- -'!1 -�....4----- ----- -------------------------------------------(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------ --------------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE-------------------------------•--------•-----------•------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------- -----------------------------------------------••--•----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------- -------------------------------------- -----------•---•--------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ ------ ------------------------------------------------ ----------------------------------- -------------------------- ---------------------------------------------------------------�A 1i� / FINAL INSPECTION BY---------------------- ---------------- Date.------- 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 : ' Revised W-2100