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APPLICATION FOR SANITATION PERMIT Permit No. ------- ------ (Complete in Duplicate) n Date Issued ___ ___._ ----- _ : 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 LOCA 16N--------- t '----------------------------- ----------- - -----------_ Owner's Name-------------✓-p - -- ---- -------- _ Phone '�rP_ ur~ Address--------------_--•-------- -- --------------- -- / Contractor's Name__. '------------------------------------------------------------------ Phone ( Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �/ Number of living units: _ _ mber of bedrooms __{ ._ Number of baths -,v<– Lot size .L�1�__/Q___�_�_a�------------------------------ Water Supply: Public system Community system F-1Private ❑ Depth to Water Table _T� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 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 com artmenfs--------------------------Size------..---------_.---------------------------------Liquid depth--------------------------Capacity Disposa Field: Distance from nearest well-----------------Distance from foundation---.----------------Distance to nearest lot line_---___-.--_...-- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french---------------------------------- 04 - Type of filter material-------------------------Depth of filter material---------------------- length------------------.-.--------------------- 04 6 ' Seepage Pit: Distance to nearest well..__.fir--------Distance fr m oun ation_____/_-----------Distan e to nearest lot lin __ -_ V1 Number of pits.---_-Y-------------Lining material__�r1.4_ '-_.Size: Diameter---- _F------Depth_._a�.�----------------- Cesspool -----------__Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_..----------_.--------------------_. ❑ Size: Diameter--------------------------------------Depth-------------------------------- - ----------------Liquid Capacity----------------------------gals. , Privy: Distance from nearest well------------------------------------------------- from nearest buildin-j----_-----_-_----___---_____-___-___.__.. t /� ❑ Distance to nearest lot line-------- ------------------------------------------------------------------------------------------------------------- ------ Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------• 9 --------------------------------------------------------------------------------------------------------------------••---•----....._------ ----------------------------------------------------------------------------------- V' ------------------------I----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ----------.-----•---------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and rules and regulations of the San Joaquin Local Health District. Si ned ---------------------------------- -- and or Contractor y:--- ---------------V-----;_J�-------------- -- -----------------------------------------------------------------------------(Title)--- - --- - - - - -- ------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 �l APPLICATION ACCEPTED BY-- - - --- - '------------------- DATE---- REVIEWEDBY�-------------------------------------------- ------------ ---------------------------------- ------------------•-------- DATE--------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------- ---------------------------- DATE--------------_-------------- Alterations and/or recommendations--------------- --- ---------------------------------------------------------------------•------•-•----------•-•--------------•- - ------------------------------------------------------------------------------------ ------------------------------------------------'•----------•-- -----.......------------------------------------------------•---------- ---------------------------------------------------------------• -•--------------------------------------------------------------------------------------------- --------------------------------------------------------- --------------------------------- ----------------------------------------------------------------------------•---•----------------•-------------------•------------------------------------------------------------------- ��/ FINAL INSPECTION BY:.,,-------- !�/f( /! ---------- 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