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y- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Data Issued 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. JOB ADDRESS AND LOCATIO l r ------------- ---------------I------------ _ ........ Phone---- ------------------------------ Owner's Name.. - ---------- --- Address rf ..... d ;�-•-_- ----------- Contractor's Name...---_--• --••--- Phone-----•--•------•------ - ------ -----•---------------------------- --------------------- ----------•--------. -------• •--------- Installation will serve: Residence ❑ A rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _____!`�lumber of bedrooms Num er of baths .-----Lot size ------------ -----`-------------------------- Water Supply: Public system ❑ Community system ❑ Private epth to Water Table 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.) Septi Tank: Distance from nearest well-_A---' ' istance from foundation---J.-Q_______- terial___ ______ ----------- _-------- _ No. of compartments---------I.-*---------Size-•-- -- - - Liquid depth---- --�------------Capacity__ --1-Q-0------ Disposal Field: Distance from nearest well-----------------b ace from�foundation._'1-r0 ------ Distance to nearest lot line__ �� ------•--•--•-- Number of lines---------------__ ---------Length of each line_____` - -----------.Width of trench_-_-__ -. ___._________.._. Type of filter material-_S Depth of filter material----1-(.......Total length______I -_____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation----------.---------Distance to nearest lot line------.._---___-_ _t ❑ Number of pits----------------------Lining material-------------- ----#r.--Size: Diameter---------- - - -------Deptln---------- ----------•••---•-----OIC Cesspool: Distance from nearest well-----------------Distance from foundation----------- ---.Lining material-_-___---_____-_____-_______________- ---- --- ------Liquid Capacity `gals ❑ Size: Diameter - Depth _ _ r ---- _ Y Privy: Distance from nearest well--------------------------------------`--- ....Distance from nearest building.----------------------------------------- ❑ Distance to nearest lot line------------------------------------- --------------------- Remodeling ----------------- # � C Remodeling and/or repairing {describe: ---------•--------------•-----------------------------------------------...--------------------- ------------------------------------------------------------------------------------------------------------ ------ --------••----------..---------------------------------------------------------------------------------- ---------------------------------- } , ------------------------- ------------•----------------•---------.-.---------•------------------------------------------- ------------------------ •---------------------------•---------•---------------------------------- I - 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 Cantractor) BY•----•••-------------------------------------- - ----- -- --- - - ------- -- ------ (Title) o (Plot plan, showing-size-of lot;location-of system in relation to wells, buildings;--etc.;-can-be-placed on reverse-side);--- 4 -- -� FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------ - --------------------------------------- -- ---------------------------------------- DATE-------------------------- ---------------- -------------- REVIEWED BY-------------------------------------------------- - 1 f ------- DATE_---- - •-•------------ BUILDING PERMIT ISSUED-------------•--------------- ------ f f�� DATE.. --------- ------ --�-} ` --•----- Alterations and/or recommendations----------------------------------- ---------------•------•--•--•-------•---•--•-•- -----•------------------------------ --------•---------------- ----------- ------ ----------------------- ---------------------------------- -- --------•---- ------ -- -- ----•------ ----------- -- ---------•------------------------- --- - ------------- FINAL INSPECTION BY:. Date- - - ------ -------------------- SAN - JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California es-4 145446 ATWOO❑ Y