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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) a Date Issued __r_____ !_ Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Zeoelc! bed. This application is made in compliance with County Ordinance No, 549. r 670_0�1- , JOB ADDRESS AND LOCATION. r 'l` ' 3 7� - --- ---------� ------------------------ ------- Owner's Name---/----• -- --- -- -------------------------- ---- "- ------------ Phone----------------------------- Address �. ---------------------------------�+'� ------------------------------------------------------------------------- Contractor's Name-.oe!;?�- ------------------------•---------------------------------------------------------------------------------------- Phone--------------------- -_---------- Installation will serve: �ResidenceA Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ----- Number of bedrooms _- Number of baths . � Lot size � ___�___ ____ _________________ __________ Water Supply: Public system ❑ Community system ❑ Private,R Depth to Water Table r-__L? ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes X No ❑ 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__S_ 'Distant fror�faundation___ ____________.Material � ^� - f 1f �j/ �p ---- --- No. of compartments___.oZ_________________Size_ "__ __f'_ ___Liquid depth.__.____ __----.-_-__.__:Capacity.��_{�'b_.____ Gv Disposal Field: Distance from nearest well . ........Distance from foundat'on__1_-___.--_-_.Distance to nearest lot lige--.__._.._. (i Number of lines -- ---- __ ength of each line__{ 0------------------- of trench--_ __------_-_________ Type of filter ma �epth of filter material--_„ fie-______._Total length_ Ca__'_______________________ Seepage Pit: Distance to near est,:weL_____ ____________:_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----------------------- ---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 and regulations of the San Joaquin Local Health District. Ll (Signed) __j................... ---------------------------•-- -------•------------ ----•-------------------(Owner and/dr Contractor) $y:---------------------------------------------------------------•------•------------------------------------------------------------(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----.. --------------------------- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE--------- ------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- --•----------- DATE---------------------------------------- Alterationsand/or recommendations:-------------------------------------,---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------- --------- --------------------------------------------------------------------•----------------------...--------------------------•- --•------------------------------------•----- ----------------------------------------------------------- ---------------------------------------------------------•---------------------------------------------------- --------------------------------------------------•------------------------------------------------------------------------------------ ------ ------------------------------ -------------------------------- ------------ --------- ------------------ . ----- --- FINAL INSPECTION BY:.- r- ,fst'-----------------•----. Date.. CG` � L ` -------------------------------•--- t 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 : Revised W-2100