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APPLICATION FOR SANITATION PERMIT Permit No - -- --- 1" 3 (Complete in Duplicate) ,j. � Date Issued ----/---.•�---- � 1 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 i ante No 549 �. JOB ADDRESS A D LOCATION________ ---------------- -•------------- ----------- Owner's Name- -- ---- - - ---_ -- ------ Phone__ __t -- -LJ-0------- Address.--••------l i ------------------ ---- ' ---------••----------------------------------------------------------- ------------------------------------------------ =-------------- Contractor's Name--- - ------ ------- - --- ---------- ----------------------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence ;Apartment House El Commercial E] Trailer Court E] Motel L) Other E]Number of living units: -A--- Number of bedrooms ___Z Number of baths ---I-- Lot size .�-�___�._�_��________----------------------- Water Supply: Public system Y/Community system ❑ Private ❑ Depth to Water Table ________ ft. oil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Character of s p � ❑ Y �` Previous Application Made: Yes ❑ No New Construction: Yes d No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted 'f public sewer is available within 200 feet}}) f Septic ank: Distance from nearest well____ _______ __Dista c� from,fou dation__ l!_________.Mat �_______ _______.________________________:... No, of compartments__________ __ __________Size :x'-- __l -____Liquid dept___ ___ _._________Capacity___LQ�_�_�_ Dispos Field: Distance from nearest-_11111-4, earest 1111E _ __ _ __ ._.Distance from foundation----_�_1______Distance to nearest lot line I- -_______. Number of lines____________ __��___________Length of each line______________]_ rf_____-Width of trench________Z'T" I._________..__ Type of filter materia 4('� p ---- ___ De #h of filter mater�al_______t-_�_______Total length______.____�_t�i_,�____ 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---------------------------ga s. - s - - -. _ a Privy: Distance from nearest well_ `_ __ _________________________ Disfarice from`nea�est building_____ -_.....-_____________________._____. [] :Distance to nearest lot line-------------------------------------------- ------------------------------------------------------------- ----------------------------------- Remodeling ---------------------- --------- Remodelingand/or repairing (describe)-----------------------------------------------------•-------------------------... -------•-------------_-----------------------------------•.-..... -----------------•------------------ ------------------ ......- -------------------------------------------•---------------•------------------------------------------•••--------------------------------•-- 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�---------------------------------------------------------- (Plo� plan, showing size of lot,-16catioof system in relation to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY --�� APPLICATIONACCEPTED BY---- ---- -------------------------------------------------------------------------------- DATE__�-------------------------------------------------- REVIEWED BY---------------------------------- ------- - --------------------- -------------------------------- ------------ DATE------_ --- -----•- - --------------------------------- BUILDING PERMIT ISSUED ------------------- DATE-------------- and/or recommendations----------------------------------------------------------------------------------------•----------•---------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- ----------------------------------------------------•------------•-••---------------------------------------- ----------- ---------------------•-----------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------- ---- -------------------------------------------- �- ---------------------------------- ----------------------------- ---------------------- --------------------- ----- --------------- ----------- ---------_-- ---� Zy- FINAL INSPECTION 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 tl ES-9-2M 8-51 Revised W-2100 F