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r APPLICATION FOR SANITATION PERMIT Permit No. ...�� ` ... (Complete in Duplicate) Date Issued ---------------- elApplica;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 C/o�unty Ordinance No. 549. JOB ADDRESS D LOCATIO�I__�- V �_.__ Owner's Name----- ------------ - -- ------------- ---------• .----------- . -------- ---------------------------------------- Phone------------------------ . .._.. _ , Address--------�--�- . -- ------- ----- Contractor's Name--- ------------------ - --------------------- ------------- -------------------------------------------- Phone----------------------------------- 1 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot?l ❑ Other, El rC: Number of living units: __- --- Number of bedrooms _Z_._ Number of baths ________ Lot size __ � __�---------------------------------____________ Water Supply: Public.system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel,E]—Sandy,toam Clay Loam E] Clay ❑ Adobe Hardpan [❑ Previous Application Made: Yes E] No � New Construction: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic +ank'or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation----.--------------.Material--------------------------------.______-._____-. ❑ No. of compartments-------------- ....--Size--------------------------------Liquid depth--------------------------Capacity....--------•---------- Disposal Field: Distance from nearest well------------ -Distance from foundation--------------------Distance to nearest lot line----------------- F1 Number of lines-----------------------------------Length of each line------------------------------Width of french---------------------.---_--------- Type of filter material_______________________Depth of filter material--------------.-------- otal length___.___________________-_________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number•� p ------ �__-Distaa ,-f-------Size: Dia meter----•-•----------------Dept n�__.��_�-��--- 1 , -Cessp ol: D sta ce fromsm st we Li n Distafer -._.__�Pundation__�_�_________:Lining material_ ___ _ _ ________________. Size: Diameter__ -_ ---Li Liquid Ca acit 2- gals. (A) Deptq P Y-......��- 9 Privy: Distance from nearest well.._._].��__________ _ _______Distance from nearest building-.-- V--- ____________.__________- r®r I lJ Distance to nearest lot line:-- ----------- ---- 11 , Remod� ng and/or repairi (describe ___________ ------- z°- --- moi _ ------------------ --------------------------••------------ --------------------------------------------------------------------------------------------------------.-...----------------------------------- --------------------------------- -------------------------------------------------------------------------------------------------------------- -----------------------------------------------r------------••------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. CtT(Signed) ....:- . _ �_41_49 ----------------------------------------------- ------(Owner and/or Contractor) --- By:----------------------------------------=---------------------!=---------------------------------------------------------------(Ti+le)--------------------------------------------- - --------------.. (Plot plan, showing size of lot, location of sys+em, n relation to wells, buildings, eta., can be placed on reverse side). »� FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- -----------------------------------------------------------------------------------•-------- DATE .,... --------------------------------------------- REVIEWED BY-------------------------------- ---- ------------ -- DATE-- � BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------ Alterafionsand/or recommend a+ions------------------------------------------------------------------------------------------------ ------------•-----•-•----------------•------------------------- ---•------------------•---------------------I--•----------------------•- ------------------------------- --------------------------•------------- -------•--------------------------------------------------------------- ----------------------------------------- -----------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------- ------------------------------------------------------------I------------------- ----- - --- - ---------- ------------------------------------ r -------------------------------------------------•--- V FINAL INSPECTION BY:------------------ �- � ---- Date-..-------------- --------------------------------------------- - ----- - ----t---y-- --- -� J- ----- 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 FS-9-2M Revised W-2100