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w Y Y APPLICATION FOR SANITATION PERMIT Permit No. ...... ._ . ------ (Complete in Duplicate) . p 's3 ` Date Issued -_�Z------____________ Applica ion 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 No. 549. JOB ADDRESS AND LOCATI T �' = c L Owner's Name -----. Phone------------------------------------ Address---------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name---------------e --•------ -_----------- --•--- ------ ----------- Phone----------------------------------- en will serve: Residence ant House ❑ Commercial ❑ Trailer Court ❑ Mofel 0 Other ❑ Number of living units: _ _____ Numb f bedrooms :�____ Number of baths______ Lot size _____--_{_ 1 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®- +iffr�"an ❑ Previous Application Made: Yes ❑ No New Cpnstruction: Yes �a- 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 .____ooe ;s#enc fro f u ation___________-A Matjr- I__ G_L : �____._____. k No. of compartments------------------- ------Size-- ------ Liqu ____- -.-- �_ Disposal Field: Distance from nearest well_ '�isfance from•foundafion___ _ .-_I_ _ istance to nearest lot line.f_ ___ Number of lines---------------k_-____.--._-- ___-:Length of each line- ------ -- 1211h of french-- _--�-+:_-- ------------------ Type or filter maferial.-�T-- Depth of filter material___. -------------Total length------------ �_________________ Seepage Pit: Disfance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---_--_______-___ ❑ Number of pits----------------------Lining material_------------.-------- Size: Diameter------------------------Depth--------------------------------- 11 � t Cesspool: Distance -from nearest well-----------------Distance from foundation--------------------:Lining material-------------------------------------- ElSize: Diameter--------------------------------------Depth------------------------------------------------------Liquid Capacity---------------------------gals. Privy: distance from nearest well-------------------------------------------------Distance from nearest building__________--_--_______________.________._. ❑ 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, State laws, and ruAs and regulations ofLfSan Joaquin Local Health District. (Signed) ---------------------_------------------------ ---------------------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 . / 7 ' REVIEWED BY-------------------------------------------- -- ---------------------------------------- DATE--------------------------------------------- ------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE.------------------------------------------------------------ Alterations and/or recommendations-----------------------.- -------.---------- ----------------------------------------------------•------------ -•--------------- ----------------------------------------------------------------------------------------------------------•----------•------------•----------------------•-•--------•-••----------•------------------------- ---------- --------------------------------------------- ---------------------------------------------------------•------------------------------------------------------------------•---•-----------------------------.-••-- ----------------------------------------------:------------------------------------------------------------------------=------------------------------------------------------ ------- --------------------------------------- --------------------------------------=------------------------------- ------------------------------ ---------------•---------------------------------------------------------------------------- ---•----------------------- FINAL INSPECTION BY:--------------- ------------- Date----------- I--- J - 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