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APPLICATION FOR SANITATION PERMIT Permit No. �________________ s (Complete in Duplicate) Date issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein escribed. This application is made in compliance with County Ordin nc No. 549 _----- - = JOB ADDRESS A"LOCTIO _- Owner's Na a------ -------- Phone i --- Address �1' `''� -- ------------••--------- -----------------------'--------------------------------------------------------------------------------------- -------------------- Contractor` Name---- ------- - --- -- - - -- ----••----•------- -------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Moottl ❑ Other ❑ Number of living units: ___�___ Number of bedrooms --I&- Number of baths __�_'-. Lot size --�_6-_____�` �� ----- ------------------------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ------- ft. Character of soil to a depth of 3 feet:. Sand ❑ Gravel ❑ Sandy Loam Clay Loam [,Clay El Adobe E] Hardpan E] I Previous Application Made: Yes [jNo W New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. __.Materiad- Septic ank: Distance from nearest well -______-Dist e Pm oundaiion____-- ____ �------- - --------- No. of compartments-------------- d/e�Ph------------41 .------Capacity____r__ __-- I Dispa Field: Distance from nearesi well _ " _-------Distance from foundation__X-0--�--_-Distance to nearest lot ,irt��___________ Number of lines__________ ___ _________ -_-Length of each line______-____/-_ _ ______-Width of trench______ _ tt ------------------- Type of filter materials _ Depth of filter material---------A__-----_____Total iength__:____ ____________________ Seepage Pit: tiDistance to nearest well--------------_-------Distance from foundation--------------------Distance to nearest lot line________________ I ❑ Number of pits-----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- t Cesspool: Distance from nearest well- __-_-----___Distance from foundation--------------------Lining material___-________-_----------______-______- ❑ Size: Diameter--- ---------------------------------Depth------------------------------.----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------- from nearest building------------------------------------------ FJ ___-___--___ __________________________❑ Distance to nearest lot lire------- --------- -------------------------------------------------------------------------------------------------------------------------- i 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 Cou t ordinances, State la�ules X�;;� San Joaquin Local Health District. ___Owner and/or Contractor t --- By: = A_9 � ---------------------------------------------------------------(Ti+le) (Plot plan, showin e of lot, location of m in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- -------------------------------------------------------------------------------- DATE--- ------------------------------------------------- REVIEWEDBY------------------ ---------- -- --------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-----------�----------------------------------------- Alterationsand/or recommendations:_�----------------------------------------------------------------------------------------------------------- -----------------•---•----------------------- ` , I ----------- ---------------------------------------------- ----------------------------=--------I----------------------------------- --------------------------------------------------------------- _____________________________________________________________j___-._____________-____....___--------_-___________________-_-_____________-_--____-____----_____-_____________________________.-________________________________ ,r f -----------------------------------------------------=-----1------------------ ---------------------- --------------------------------------------------------------------•--------------------------------------- FINAL INSPECTION BY:--- � --------------------------- Date---- 1_-0 - - ------------=--------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 1 132 Sycamore Street' 814 North "C" Street a Stockton. California 1 Lodi, California Manteca, California Tracy, California ES-9-2M 851 Revised W-2100