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APPLICATION FOP ' r.. -SANITATION PERMIT Permit No. - ' i (Complete in Duplicate) -K I Date Issued � 1 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 Ordinance No. 549. JOB ADDRESS ND LOCATION_ -_ --------- ----------- ----------------------- ----- -------------------------------------------------------------------------------------- Owner's Name-- ---------------- - ----- -- -------- ------------- -------- ------- --------- ------- ---- - -- ------------ ----- -------- -- Phone---------- _- --------------------- Address------------ ---------- - ----- -- �-- t e Contractor's Name---------•---------•-• -•-_---- •- -----•----•- ------•---------------------- -- -- --------------- - Phone Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E]/'Motel ❑ Other Number of living units: - Number of bedrooms Number of baths I--- Lot size IP Water Supply: Public system Community system ❑ Private [I Depth to Water Table _ Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy.Loam Clay Loam WO-a-y ❑ Adobe E❑ Hardpan ❑ ((,, Previous Application Made: Yes ❑ No V New Construction: Yes [ N0 ❑ V� TYPE OF INSTALLATION AND SPECIFICATIONS: �3 (No septic tank or cesspool p jrmitfed if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welL- --------------Distant fro f and f n---�_o -------- __ --- Maternal--- --------- er No. of tom artments- - -------- p - 5�ze- - _ Liquid dep#h-------------- Ca acit P Y �if Disposal Field: Distance from nearest well__---_ Distance from foundation- _ _ h�� __-Distance to nearest to li Number of lines_________a__ 1__. _Length of each line-------- hr__ __ Width of trench-- _.- _ _ Type of filter material �/ p �� ------- -epth of filter maferial---------- ----- ------------------ ' -------Total length-----=-,------�------ ------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------_------------Distance to nearest lot line__------_-----___ El _-----------,------ ze:Number of Pits----------------------Lining material---- . SiDiameter----------- - ---- .-----.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 !ine_________________ -------------------------------------- - ------------------------------------- Remodeling and/or repairing (describe)___________________________________ _ I --------------------------------------------------------- ----------------------------- ---------------------------- -------------------------- ---=-------•-- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------__ 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 reg�tlatibns of the San Joaquin Local Health District. (Signed)-------------- ------ ------ 1 -- �A (Owner and/or Contractor BY' :-•- -------- A - (Title}_ (Plot plan, siotving size f let, location,of sysfe din elation to wells, buildings, etc., can be placed on reverse side}. � FOR DEPARTMENT USE ONLY . , APPLICATION ACCEPTED BY------ -- - --------------------------------------- DATE REVIEWEDBY ----- ------- ------------------------------------------------------------------------------ DATE BUILDING PERMIT ISSUED-----------------�___ ------ -------------------------•- -------------------- ---------- DATE-- --------,- �---- ------------------ Alterations and/or recommendations--------------- ----------- ----------------------------- --------------------- --- --------------- ---------------------------- ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:----------------------------tu/V. , Date V------ ---- - ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100