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APPLICATION FOR SANITATION ,P.ERMIT Permit No.X_, P -----__._ r (Complete in,Duplicate) � Date Issued __-- 5 - G 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 AND Owner's Narne- ----- -------•--•-------•------------------------ ------- Phone----------------------------------- �. I Address................. ---------------------••--------- v-----•-------------------------------------------------- Contractor's Name `-------•----•�---------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/------ Number of.bedrooms _T__ Number of baths /--_- Lot size _/OQX_ b Water Supply:. Public system ❑ Community system ❑ Private$ Depth to Water Table ?___ ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No �Z New Construction: Yesx No ❑ a, 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__ r_---.-.Material-,4Ad_ ____________________- ( No..of compartments----1------------------Size-?Y`1X_1------------Liquid depth_5-�-- ------Capacity--- �-o-------- O Disposal Field: Distance from nearest well-SSD__- _._Distance from foundation-- �----__---Distance to nearest lot line-_�--�--_---. .. f Number of lines_--- -------------- Length of each line- -- -- ' --- Width of trench__,• �-``--------------- t Type of filter material. -_-__4----------Depth of filter material--1 --- ------Total IengFh-_____Ae 3----------------- 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------------------------------------- - - ,,?alc �'• ❑ Size: Diameter----------- -------------------Depth---- ----------------------- - --------- ---Liquid Capacity----,-_T_-w-,,--_ -; -_ Privy: Distance from nearest-weli�:-.z�- --_--- �_�-- ___-Distance from nearest buiidin _ ....-- -..- g----------------------------------------- -. --�-� D-`"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 and regulations of the San Joaquin Local Health District. (Signed)-- ---- -..._ �4 ---------------------------------------------------------------------------------------------(Owner and/or Contractor) By: = ---- ---=------------------------•--------- -----(Title)-------------------------------------w------------------------- (Piot 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 - ----'7 ","`------------------ -------- ' DATE-_ f... - -_�-�-: � ---••----------- k BUILDING PERMIT ISSUED ----- t� ^.---------------------- DATE---- r Alterations and/or recommendations:----------------------------------- ------_--------------------____-- ------------------------------------------A00 ��--------------N a�------- ----------• -----:------ •- -------------------------------------------------------------------------------------------- -_-------------------------• ------------ ---------------------------------------------------------------------- ---------------- --------------------------------------------------------- -------------------------------------------------------------------------- k ------------=------------------------------------------------------ --------------------------------`--------- ------------------------------------------------------------------.----------------------------------------- ry € FINAL INSPECTION BY: �' -I------------------------------------ Date_ 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 ES-9-----2M 5-SI Revised W-2100