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APPLICATION FOR SANITATION PERMIT pt"'it No. (Complete in Duplicate) ~ µ 'Date 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 No. 549. f JOB ADDRES AND LOCATkON.---------------i+0--- -------- ------- ` ---------------------------------- Owner's Name------ -----•-------- c � Phone_ Address------------------ ............. ...........;-------•-------------------------.------'-------------------------------------------------------------------------------.........- ----------------------- Contractor's Name----------------------- ---------&---------------------------------------------------------------------=--------- Phone---------------------- ------------ Installation will serve: Res idence"�Apartment House -[] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: I------- Number of bedrooms A_____ Number of baths _f----- Lot size ------�___�---_�.. -�........--------- Water Supply: Public system ❑ Community system ❑ PrivatIV Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobe Hardpan ❑ Previous Application Made: YesV No ❑ . New Construction: Yes No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet:)=..• I Septi lank: Distance from nearest well Dista e from foundation___�_�,2_ ,_Mate iai_____ __ "�' --- 1a �6t I,d,T IIY�, No. of compartments-------- - ----------Size-- --x-- -- -`S---Liquid depth---------�"---.--------Capacity------i, r} I Disposal Field: Distance from nearest well------------------Distance from foundation----___-------------Distance to nearest lot line_______-___-___ 1 [] Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------_----- -_- Type of filter material-------------------------Depth of filter material-________________--_-_Total length--------------------.___-_-_______________ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------........Distance to nearest lot line____-_--_________ ❑ Number of pits----------------------Lining material------------=----------Size: Diameter-----------------------Depth------------------ --- ------____-- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------- f�4 t ❑ Size: Diameter--------------------------------------Qepth---------------------------------------------- -----Liquid Capacity----------------------------gals. V" Privy: Distance from nearest well-----------------------------------------------_-Distance from nearest building_____.._________---._-_-____________-__-. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------=-- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ` -----------_________________________________________________L___________-____._________--_____.-_____________-________-___________-__---__-___________________________.__________________-_--.__-_______-_-________________._ � 4 k ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1 y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws and rules and regulatio s of the San Joaquin Local Health District. (Signed)------ ----- ----- ------- ----------------------------------------------- {Owner and/or Contractor) ---------------- (Plotplan, showing size of lot, location Title By:------ ------- -------------------- - -------- - ------------------- ------------- -------------------------------------( �(Title)------------------------------------------------- (Plot of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- -------------- ,----- -------------------------------=-------- DATE --- - 7 ,;--------- REVIEWEDBY------------------------------------------------- ----------------------------- ---------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------------- Alterations and/or recommendations:-------- ------ ----- ---------------------------------------------------------- ----------��--------••-----•--------- - ---- }`----- ----_ -- - - - -- - ----- ----------- r - -- ---•--- ------ - .. - -� °'.r ---------------------- 'S w' ----` -----�----------- ------------------------------- -- ------ - -- -- ''� � ----'� ' ---------se ? -----.-r�--�--------------- �� . � FINALINSPECTION 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 5-51 Revised W-2100