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5 APPLICATION FOR SANITATION PERMIT Permit No (Complete in Duplicate) �� ^j Date 'Issued ___ ------______ 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 Orclinanige No. 549. i JOB ADDRESS D O ATION. ® *- -------------------------- -------- Owner's Name------------ -------- - ----------------------------------------------- ----- Phone- "q_' ---- --- Address------- C55124. -- --- -- --- --- Contractor's Name:. ------------------------------------------------ ----------- Phone----------------------------------- ---------- will serve: Residence ❑ Apartment House ❑ Commercial railer Court ❑ Motel ❑ Other ❑ Number`of living units: __ ___ Number of bedrooms ' -___ Number of baths -*Lot size __± __1_____y__ Z _1--------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam E] Clay ❑ Adobe Hardpan E]Previous Application Made: Yes E] No New Construction: Yes N0 ❑ 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--------------------Material____-------____--________-_____________-.-_---- ❑ No. of compartments------ -----------------Size--------------------------------Liquid depth--------------------------Capacity-------------I-------'= } Dispos field: Distance from nearest well -Distance from foundation istance to nearest lot li e [► Number of lines________41_-�_W_ �Qepth _ _ _______ Length of each line____--� {____.Width of trench_______ _ jj t --------- Type of filter materi 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----------------.---------------- Gess ol: 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----------------- --- - ----•------------------ ------------------------ ----------------------------- Remodel g and/or repairing (d scriba :..____-____ - -------- - --- -------------------------------------------------------------------------------------------------•.------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and' regulations of the San Joaquin Local Health District. (Signed) -_!+.G�'ITt , ----------------------------------------------------------------------------------(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 - DATEe - -------------------------------------------------- REVIEWEDBY------------------------------- - ----------------- ------------------------------------------ DATE- - ------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------r- ------------ ------------------------------------ Al enation and recommgn tions: - ------- - --------- ----- - ----------------------------------- ------------ ------------------------ -- -- v ------------ ------------------------------- -------------------------------- ----------------------------------------- -------------------------------- ----------------------------------- --- ---------------------------------------------------------------'------------------------------------- f 5 11NAL INSPECTION BY: ,' K Date /- ----------------------------- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT I30 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca. California Tracy, California ES-9-2M 8-51 Revised W-2100