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APPLICATION FOR SANITATION PERMIT Permit No. k, (Complete in Duplicate) Date Issued ___ 7 Application 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 Ro, S49e/' JOB ADDRESS. A DCAT .____�-___{!___ ___ - ------------------------------------------------------------------------------------- -------- r Owner's Name. 9 ------ Phone------------------------------------ - -- -- ------------- - -- --------------- ----- Name--- ------------------ --------- ----------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Othel!r�� j Number of living units: ____I_ Number of bedrooms __& Number o aths - �___ Lot size -- �'?.____--x. v V Water Supply: Public system ❑ Community system '❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand P Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ . Previous Application Made: Yes ❑ No e New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic sewer is available within 200 feet. Septic ank: Distance from nearest well_�j_ _--Q Dista ce from) found tion_____!/____---__.Material_______________________________ No. of compartments __.__._ Size _ _c �"�x 1Q Li u id de tj�______________ Capacity P q -------- P Y _7 Cb Field; Distance from nearest wj_. Q Distance from foundation________ __4----Distance to nearest lot,,i fii e---------- --------- Pe Number of lines___ __ _________ Length of each line__________l_�__ ________.Width of trench_ _ _ -I_Type of filter material__ l � pth of filter maferial--------�--------------Total length-------- Seepage _ ______________________ Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line_________________ f- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h-------------------------_------ I 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----- __________________ --------------- ❑ Distance to nearest lot line---------------------------.--__------------------__ Remodelingand/or repairing {describe)--------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------- -------------- - . ------ r --------------------------------------------------------------------------------------------------------------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County rt ordinances, State laws, and r4l s and regulaf tions of the San Joaquin Local Health District. (Sign ed)-----,)�--------c --K---- -- --------------=------------------------------------------------------------------------- --(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 APPLICATIONACCEPTED BY------------------ -------- ---------------------------------------------------------------------- DATE----------------------------------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------- ------------- DATE--------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------•--------------- + -----------------------------------•----------------------- -------------------------------------------- ------------------------------------------------------------------ -------------------------- -----------------.---- ------------------------•---------------•----------------- ----------- ----------------------------------------- ------------------------------ ------------------------------------------------ ------ FINAL INSPECTION BY---------------V V-- ---------------- Date---------- -V�_-['_ _ 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-S1 Revised W-2100