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APPLICATION FOR SANITATION PERMIT Permit No. _S/ 3 .� ... (Complete in Duplicate) 1 � -- Date issued --- _I�5_. Applica*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 County Ordinance No. 549- JOS ADDRESS ANDJ�LOATaON....C: a) z--,_ ------ c.---•-----------•-----------:--- ------------------------------------------------ Owner's Name_ l.rC -- ------------------------------ ---- ------•---------------------------- - Phone Address......... ('�- r---------- - f � ' Contractor's Name_. 1?------- ----------------------------------------------------------------------------------------------------------- Phone.---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .}f.__-_ Number of bedrooms -------- 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 ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes [] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank 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___________._____ ❑ 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---.-------------------__-____.______. ❑ Size: Diameter-------------- ------Depth----------------------------------------------------Liquid Capacity---------------------------gals. , Priv Distance from nearest well-________________________________ ----__--.---..-Distance from nearest buildin `� y� g -- ----------------------------------- tet) Distance to nearest lot line________.______ !" '- ----- --------- _- "--- ---� Remodeling anql/or repairing (describe):,- -�. /"__ -____-- f .. - 'tP�cl' --------- -----------------------------------------------------------�_.�___--------- -----------------------------------------------------------•--------------------------e------------------------------- -------------------- v � -------------------------------------------------------------- ----....--------------------------------------•---------------------------------------------------------------------------------------- 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. {Signed]_. -�- -�!�?-- _ ,_____ ______�_ __ ._ __ ------------------------------------------------------------(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 --; ------------•---- BUILDINGPERMIT ISSUED --------------------------------------•--------------------------------------- DATE-------�N----------------------------------------------- Alterations and/or recommendations:-----•------------......=-------- ----------------------•--------.-_---------...._. ---------------------------------• ------....------------------------ -------------------------------------•------------- -----------------------------------------------------------•--------------------------------------------------- --•------------------------------------------- i ------------------------------------------------_-----------------------------------------------------_______----------------------------------------------------------------------------------------------------------------- -------------------------------------------- FINAL INSPECTION BY: ='' ---------�4' �,:"l<' __ '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-2100