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APPLICATION FOR SANITATION PERMIT Permit No. -- .� (Complete in Duplicate) �l Date Issued Application is hereby made tb the San Joaquin Local Health District for a permit to onstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. .L� �L JOS ADDRESS AND L T€ON r � ` ----------------------------------- Owner's Name- ---------------------------------------------------------------------------- Phone.- _- Address ----•--- =- ------------------------------------------------------------------------------------------------ V Contractor's Name------------ -- - ----- -------• ------------------------------ PhoneF, q- Installation will serve: ResidenceIV Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ �_Aumber of bedrooms _ Number of baths /----- Lot size ----- ---------------------_ Water_Supply: Public system Community system ❑ Private ❑ Depth to Water Tab€e�D ft. Character of soil to a depth of 3 feet: Sand E], Grave€ ElSandyLoam ❑ Clay Loam [❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑_No �' New Construction: Yes [: NA TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is avhilable within 200 feet.) Distancefrom foundation--------•----------.Material---------- --------------------------------------� SeptiDistance No. of comp artments- well ------------Size------••------------------------Liquid -depth------------ ------------Capacity-_-------------------` , Disposal Field: Distance from nearest well-----------------Distancejfrom foundation.-__--_---.-----.-.Distance to nearest lot line----------------- 5 Number ai lines --------------------- Length_of each line------------------------------Width of trench--------------------------------•-- � Type of filter material-------------------------Depth of filter material------.- --------Total length------------------------------------------ Se e -----------------.---.-__--------------_See Pit: Distance to nearest well-/ /-_. Distancefr fou -`""_at _--Distance to nearest lot line------ Number of pits------- -.--- Lining mate*ial, en Size: Diameter-.--- _ ._______-Dept h_.--.��I------------- Cesspo(7:- ---- Distance-from-nearest well--------"_':Distance from foundation._'_ '------.Lining material------------------------------------- ❑ Size: Diameter------ ------------------------------Depth----------------------------------- ------- --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building----------------------------------.------- ❑ Distance to nearest lot line--.---- ---------------------------- -- -------- Remodeling and/or repairing (describe):----------- _� --- ------------------------------------------------------------ Remodeling --------------I----------------------------------------------------__1 -------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------- ----------------------------------------•---------------------------------------- --------------------------••----•------------------------------------------------------------------------------------------. I hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, State laws, and r s and regulations of the Sa Joaquin Local-Health District. (Signed)--------------- ---------- -- -------- _crCr ------------------------------------------------- - -(Owner an r Contractor} By:------•----- -------- - ---[Tt[e}_ ' :-- (Plot plan, showing size of I , location of system in relation to wells, buildings, etc., can be pla on reverse srde). IFOR,DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------- -------------------- DATE--------- REVIEWEDBY--------------------------------------------------------------------------------------- ------------------------------------- DATE-------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------= Alterationsand/or recommendations---------------- --------- -------- -------------------•------------------------•-----------------•--------------------...------•-----------•------------------- _ , ---------------------------------------------------------- ------------------- -------------------------- -------------- •--------------------------------------------------------- ---•--------------- -------------------- ------------- - ------------------ --------------------------------------------- ------------------------- FINAL INSPECTION BY:----- --- Date------ f ---- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT y 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street i Stockton, California Lodi, California Manteca, California Tracy, California F,5-9-2M I0-52 Revised W-2100 f