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APPLICATION FOR SANITATION PERMIT Permit No.��_.------.---••-------- tComplete in Duplicate) Date Issueds Application is he 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 rdinance No. 549 JOB ADDRESS A LOCATI - Phone- --------------------------- Owner s Name------------ --- -------------- ----------------------------------------------------------------•---•-•--- Contrac#or's Name--- ----------------- ----- --=--•--------------------------------------- ------------------------------------------------------------ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Installation will serve: Residence Apartment House ❑ / f Number of living units: -V umber of bedrooms ---I_:"Number of baths ---,i___ Lot size __--_----- _ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Adobe ,`Hardpan Sand Gravel F1Sandy Lo;PN,o Clay Loam ❑ Clay [3I�!" El Character of soil to a depth of 3 feet ❑Previous Applica#ion Made: Yes ❑ No I/ New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Q i (No,septic tank or cesspool perm*+ted 'f public se or is available within 200 feet.) I �1 � f --- --------------- 4 �� istanc? fro four�ation-_---r_ --------Mat ri�l_----__----- { Septic/Tank: Distance from nearest well- - 1 ' q P Capacity-_. --� -r-` No. of compartments------- - aE •x - --•-------Liquid de �h-------- -- - - -- �- --Distance to nearest lot Ii e - -------• i Disposa ield: Distance from nearest II_- *stance from foundation_-- Width of trench-- _---- Zi Number of lines----------- ---- --- --- - --Length of each line--------------- - s� �` f }�0 Total length.--- 5�O--------"----------------- Type of filter mater epth of filter material_--_-_�-C.t---- Seepage Pit: Distance to nearest well------_--------------Distance from foundation-------------------.Distance to nearest Iot line---._____---_--_.. k ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------ Cesspool: Distance from nearest well----------------Distance from foundation----_-----_--- Liinuid Capacity egals. ❑ Size: Diameter--=----------------------------------Depth--------------------------------------------------- q ---- "" Distance from nearest well----------------------------------- ----------Distance from nearest buil Ing-.---------------------•--------•--------• Privy: r ---- -------------- Cl Distance to nearest of line------------------------------------------------ r ----------- Remodeling and/or repairing (describe)--- ---------------------- n --------------------------------- ••----------------------- 'l ----------------•-------•- w -=---------------------- -----•------------------• - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I , and rules and regulations of the San Joaquin Local Health District. Ot ( ------------------------------------------------------ r and/or Contractor) [Owne d/o or) ° Si ned _ ------------- ! t ig ) = --- --•-------------------- BY:---------------- - ----------------------------------------------------------------------------------ice"---------•---• iitl ----------------------------------------------------------- w ----------------- ------------------------------------ - t Plot plan, showing ' of lot, loca+ion of sys+emQin relation to wells, buildings, etc., can beplacedon reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY� ----------- DATE_ --------•------ - DATE �--•----------------------------------------- REVIEWED BY--•-------------------------- BUILDING PERMIT ISSUED------------- ------------------------------------ Al+ex ons and/pr recommends#"ons: -�=----n------------- 7� l ---- ... - ------------------------------'------- ----------- A------------------V•-.--_-__� ----•__---__-------____-_"-----_-___------ ------------------ ----------------------•__------- --------------------------------------- ----------------- ---------------------- Date------------- ----------- -------------------•--•- FINAL INSPECTION BY: -- ---- ------L----------------------------- - SAN JOAQU.IN LOCAL HEALTH DISTRICT i 132 sycamore Street 814 North "C" Street 130 South American Street 306 West Oak Street Y Trac California Stockton, California Lodi, California Manteca, California Y• ES 9-2M 8-51 Revised W-2100