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z � APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / f—,2j Date Issued ---------- ------------- 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. JOB ADDRESS AND LOCATION-------------1 7 ------ --- .----------------------------------------------------------------- [� Owner's Name �-------- Phone Address --- --. ---- -------- ---------- Contractor's Name-------•-•--------- ---- ------- ------------------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence [;f--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _3 Number of bedrooms --�_ Number of bathsot size ---Sv�_ �")(/ f -r -------------------------------- Water Supply: Public system �ammunity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ElClay E-1Adobe [�ardpan E]Previous Application Made: Yes E] No �� New Construction: Yes / No ❑ ` TYPE OF INSTALLATION AND SPECIFICATIONS: V (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well"_ Distancg from foundation______________ _____Material___ ._ 911/ No. of compartments_________________Size---- ___ __ _;S iquid depth_3_,ti----_____Capacity___ b_____ Disposal Field: Distance from nearest well_--AA-_f__.Distance from foundation---/0...........Distance to nearest lot lines''....... Number of lines-___3____ __________ _ Length of each iine_ i1_r_ �iY:atCVidth of french.____ ___ ----------------- Type of filter material- =________Depth of filter material----I_"'d_-"-_Total length----_S_----Q-_-�_________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation____----------------Distance to nearest lot line_-_______________ ` ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: ---- ----- "---------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------- ------" Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth---------------------------------------ti------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----________________________-_________._______Distance from nearest building_..------e______-_-_,_: _;_____ . ❑ Distance to nearest lot line-------------------------- ------------------------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe)----------------------------------------------------------------------------------------------- --•-I-------•---------------------- ------------------- ------------------------------------------------------------------------------------------_-----.------------------.---------------------------------•----------------------_----------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------•-------------------------------------- 1 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 regulations of the San Joaquin Local Health District. (Signed)- ----- 1 "---- ------------------------------------------------------------------(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----- .., REVIEWED BY_... .�.- �-- -- - -- - ------------------------- DATE---- -- - - --------- ------ BUILDING PERMIT ISSUED--------------------------- ------- ----------------------------------------- DATE---- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------•--------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------•------- ----------------•-- -------------------------------------------------- ---------------------------------------------- ------- •------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:-,/�_, _ _.----_-_--_-_-------_------------------------------------ Date------ --------------------------------------- SAN ---- ________ "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