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F APPLICATION FOR SANITATION PERMIT Permit No. -_3_ __�� (Complete in Duplicate) Date Issued ________17./-___ 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 A LOCA ION____ _ _ Owner's Name ------------ Phone -- ---��--------�r-� ---- -----•-------------- -- ------•--------- ------------------ --------------------- ---------- Address---_____16_ a Contractor's Name----- •----------- ---•-- ----------------- -- ---------------------- -----------------------------------------------•-------------- Phone------------------------------------ Installation will serve: Residence Apartment blouse ❑ Commercial ❑ Trailer Court E] Motel E] Other Number of living units: ___'___ umber of bedrooms .-X_ Number of baths ---/--- Lot size ___________________________________----_-__________________ Water Supply: Public system [Community system F❑ 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.) Sptjc T k- Distance from nearest well-________-------Distance from foundation_____________ l- _____Material----------------------- No. of compartments--------------------------Size-------.------------- ----------Liquid depth--------------------------Capacity------------------ ` D-spgsal Fie 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-------------------------------------- 0 Size: Diameter-------------------------------- -----Depth----------------- --------------------------- ------Liquid Capacity---------•----------------•-gals.C Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__________-___-_-__________-____----- ❑ Distance to nearest lot line--------------------- -------------------------------------------------------------------------------------------- --------------- Remodelin and/or; reppiring (des ribe):--c-------- ----- - - ° ---•--------------------- ---- •--------- - ---.• -- -- - - -----------------•-------- --- --------- -- ------- -•=---- --------------- --- --=--•---- -•-•----------•---------------------•----•--•--------------------------••-------------------- ----------------------------- ------------------------------------ •------- ---------------••-----------------------------------------------------------•-------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f ordinances, Stat laws, and rules and' regulations of the San Joaquin Local Health District. (Signed) ----- Q ---- ------- --------------------------------------------------------------------------•-----(Owner and/or Contract By: ----- � ----------------------------------------•-------------------------------(Title)---------------------=------------------------------------------ (Plot plan, showing size of lot, system in relation to wells, buildings, etc., can be placed on reverse side). 2 T F. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-l' Y- -------------•--------------------------------- ----------------------------------------- DAT REVIEWEDBY----------------------------- DATE------ ---------------------------------------------- BUILDING PERMIT ISSUED----------------•- - ------------------------------------------------------------------------------- DATE----=------ ------------------------------------------ - Alterationsand/or recommendations:--------------------------------------------------------------------------------------'----------------------------._-.._....------•------------------------ ---------•---------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------•------•-------•- •----- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------ -------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- -------------------------------------------- FINALINSPECTION BY:------ - ---------------------------------------------------- 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-4-2M 8-51 Revised W-2100