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APPLICATION FOR SANITATION PERMIT Permit No.�_�___ ____________ (Complete in Duplicate) q ' D 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 Ord- a ce No. 549. t � T . ' 4 JOB ADDRESS A L ATI N.... ---I - ..__•--._ _ Owner's Na e._ ----- --- ---•----------------------- --- ------------------------------------------ ------------- Phone-9__" < Address--------••9•• 2.-M ----'..---•---- ------ -------------------------•- .........- Contractor's Name----- --------- ----------- ------------------------------------ ---------------------------------------------------- Phone-----------•--•----_---------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑/ Other ❑ Number of living units- umber of bedrooms .Z-. Number of baths ---I--- Lot size __ _.k-!' ------------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel L] Sandy LClay Loam E] Clay E] Adobe Hardpan F]Previous Application Made: Yes F] No New Construction: Yesoam No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted ' ublic se r is available within 200 feetAl Septic ank: Distance from nearest well s isfa afrooun n .O_._.___..Mate i�l_______________________ ______ No. of compartments_____. __ __.__.. Size_ a' Liquid 77depth__--_-.�-------------Capacity-_-- ------ Dispo Field: Distance from nearest ---" e1 .Distance from foundation-1-h---------Distance to nearest lot -n 5_ Number of lines----------- ------ ------.. -- Length of each line----- +�_._---.Width of trench-__-_-- _-_-- _..____-__-- Type of filter mated _-�pth of filter material-.-.-_1. ----------Total length--------.�. ---------------_--__ Seepage Pit: Distance to nearest well----------------------.............Distance from foundation--------------------Distance to nearest lot line-_-._---..-----_ NZ ❑ 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--------- ------------------------------------ ----------------------- -------- ---------------------------------------------- Remodelingand/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 law nd rul s and regulations of the San Joaquin Local Health District. � f t Si ned {Owner and/or Contractor) C� 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 BYV--------- --------------------------------------------------•---•-------------------- DAT -- - ---------------------- - I REVIEWEDBY------------ --------------------------------------------------------------------------- --------- DATE_ BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------- ---- Alter tions and/or recommendations:----------_---------- -- V _ � ------ - A _ � s .- .��. ,..�,az := --- ----------- ------ -- - - --- -------------------------- --------------- ---------------------------------------------------------------------------------------------------V---------------------••-------------------------------------- --------------------------- ------- --------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- ------------------ - -—--------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:----------------- "-71s Date-- ------------------------------------------- ti 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 I0-52 Revised W-2100