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a APPLICATION FOR SANITATION PERMIT Permit No. ---- (Complete in Duplicate) -a; Date Issued ___ -Le .� Applica+-ion is hereby made to the San Joaquin Local Health Disfrict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinanc o. 549. JOB ADDRESS AND L ATIO ... 1 - ----------- Owner's Name________._ •1 Phone. M � � Address✓„ -------------------•-••----•--- Contractor's Name------ ---------- ------------------------- -------------------------------------- Phone--�----- � /- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other/❑ ' Number of living units: /_-_- Number of bedrooms._ Number of baths _/___ Lot size _�f+ ------------------------- Water Supply: Public system"Community system ❑ Private ❑ Depth to Water Tabl@✓ #t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe k"' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YesX No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I ptic Ta.0 k: Distance from nearest well-----------------Distance from foundation--------------------Material---------------------------.-_-____.__________- No. of compartments--------------- ---------Size--------------------------------Liquid depth-------------- -----------Capacity---------------------- Dispos I Fie Distance from nearest well-_--------------Distance from foundation--------------------Distance to nearest lot line-_-__-_-_________ P Number of lines-----------------------------------Length of each line---------------------------.-.Width of trench------_----_----------------------- Type of filter material_________________________Depth of filter material-------------------=__Total length________._-.----____-_______________--____ Seepa e Pit: Distance to nearest wellL. ''___Distance m,fo dation___ -�___..Dis ary/e to nearest lot I;e____�"__ { ' Number of pits---- --------------Lining materia 1-e- 2 ___ Size: iameter----- ---------Depth r-----r�� _ _a Cesspool: Distance from nearest well_.___________.__Dista`n`c-ee from foundation--------------------Lining material__..__---___--.____________________-. ❑ Size: Diameter-------------------------- ----- ----Depth---------------------------------------------------.Liquid Capacity------------------------..._gals. Privy: _ Distance.from nearest well_______________________ ___________ _______'i'Distance from-nearest--building________-: ___�_ -_-_'_. 4 ❑ Distance to nearest lot line________________________. __ 6 Remodel ng and/or repairing (de tribe):__-_ _ s_ :__ �_ �--------- ------------ ---- _ - ----------- --- ------•------•---- =---- ;-- --------- ---•------------------------- l - -------2:� c � ---------------- ... - -- 4r ------ ----- - ------•----------------------------••----•----------------•-•------------ I hereby certify4hat I have prepared this application and that the work will be done in accordance with San Joaquin County . ordinances, State4aws, and*Pule and regulations of the San Joaquin Local Health District. op ------------- -t whet and/or Contractor (Signed}_______� - : J / ) By:-•----------------------------------l�Y' Title x i --------- ---- --- - •I-- --- ---- - - --- - - - (Plot plan, showing size of lot, location o system in relation to wells, buildings, etc., can be pla ed-on r4erse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------------------------------ - - ----�--- DATE-----------•---•- ----------------------- ----------------- REVIEWED BY ---------------------------� DATE - " _ _._.... jV BUILDING PERMIT ISSUED -------------------- --------------------------------------------•---.------------ DATE---------- Alterations and/or recommendations------------------------------------------------ -------------------------------------------------•-----...--•-••-•-------------------------------------------- ------------------------------ -----------------------------------------------------------------------------------•----- •------------------•--------------------------------------------• -•••------------------------------ t --------------- ----------------------------------- ---------- ------- -------------------------------------------------------------------------•-••--------------------------------------------•---•------------------- •------------------------------------------------------------------ ----------------- --------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------- -----•-------------------------------------------------------- -------- FINAL INSPECTION 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 : Revised W-21DD