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x APPLICATION FOR SANITATION PERMIT Permit No. ....J.__._---_.-------.- (Complete in Duplicate) / Date 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 yit Coun y Ordinance No. 549, JOB ADDRESS AN LO ATI ` ------- ------------------- ----- ,�q ------------------------- Owner's Name----- L, i ��`-- -----•---- ------- --- - -- -----•----------------------- ---._ Phone _ Address------------ `�---- --- Contractor's Name----- -------- --- -- --------------------------------------------------------------------------•---------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trail rg�ourt ❑ Mot11I ❑ Other ❑ Number of living units: ....L Number of bedrooms -%3-_ Number of baths u(yxot size I o __ .�-+ ---------------Water Supply: Public system E] Community system ❑ Private Depth to Water Table -------- ft. v Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam El Clay Loam E] Clay [-] Adobe 21/Hardpan E]Previous Application Made: Yes E] No New Construction: Yes eNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 10 (No septic tank or cesspool permitted if publi sewer 's available within 200 feet.) Septic ank: Distance from nearest well--v� nce� fromf,foun ation__�_____ Mat rpl------ ----- 3� No. of compartments----------- - -X-q ----Liquid th-----. .--.-----------Ca acit � �---- ,,,,,�� p Capacity Field: Distance from nearest well Distance from foundation__/ __r�`'_�"Distance to nearest lot ine.__'�_____-- Number of lines___________ ___ _____Length of each line--------- Q Width of trench..--_/�r_- Type of filter matersTi�p r - -- __ epth of filter material length--------__-�-- -,0----------------- Seepage Pit: Distance to nearest well---______-___________Distance from foundation--------------------Distance to nearest lot line_______-_________ s ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth__.-------------------------_ Cesspool: Distance from nearest well---------_-------Distance from foundation------- ------------Lining material:_____.-_____________-______________. ❑ Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_____----__________ _________________________Distance from nearest building_-----___.-_._______-.- ❑ Distance to nearest lot line-------- ---------------------------- Remodeling and/or repairing (describe)---------------------------------------------------------------------•----------------•------------------------ ` --------•-----•-------------------• ---------•-----------------------------------------•-------------•-------------------••-•-------- ------------------------------------------- ----------- ---------------------------------------------------------------•-------------------------------------•----------------------------------------•---•-----••-----------------•----------------------•---------------- 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 a d regulati ns 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---iP -----------• --------------------------- BUILDING PERMIT ISSUED------ . -•----------------------------------------------•-------- ---------------------------•-- DATE. Alte A sand or recommend inns: i ----- ------------------ chi'--- -- --------- -- ---- ---------- -------------•-------------------------------------------- ----------' -------------------------- ---------------------------------------------------------- .-•--- FINAL INSPECTION BY:--- ------ Date--- -��:C! 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