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v- ,: 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO ATION_____LD - Owner's Name- ------- ---- Phone-1?f/ e------- Address----------- - -- - Contractor's Name ---- ----------------------- Phone -------------------------------------------------= Installation" will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel . Other ❑ y Number of livingunits: -_______ Number of bedroom Number of baths I---_ Lot size -- - ------------------ Water Supply: Public system Community system ❑ Private E❑ Depth to Water Table -------- ft. f Character of soil to a depth of 3 feet: Sand Gravel , Sand Loam Clay Loam Cla ❑ Y ❑ y ❑ y ❑ Adobe❑ Hardpan � Previous Application Made: Yes ❑ No New Construction: Yes 2-IN, ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Q (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-________________Distance from foundation----------- ____-_ -± , _ --- -- ---.Material------------ ❑�r f, No. of compartments-------------------------Size- ----------------------------.Liquid depth-----.-------------------.Capacity a _ _ Distance to nearest lot linef_� _______ Oi Disposal field: Distance from nearest well_____`_—_____.Distance from foundation______-__ - . Number of lines------ __-____ Length of each line___�[1� Q -Width of tren / Type of filter material__, ___Li!---------Depth 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------------------- -------------- ----------- Cesspool: Distance from nearest well_ _______________ Distance from foundation------------------- Lining material-__.__________._-____ - -------------- y ❑ Size: Diameter---I---------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. it Privy: Distance from nearest well-------------------------------------------------Distance from nearest building --------------------- ,; ❑ Distance to nearest lot line.___---____. I ------- -------- Remodeling and/or repairing {describ -___ 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 I ws, and rules and regulationsofthe San Joaquin Local Health District. i (Signed) � ----------------------------(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 rey9yre side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ DATE _. ; REVIEWED BY ----------------------------- ------- DATE BUILDING PERMIT ISSUED---------------------------- ----------------- DATE -------------------------------------------------------- ------------------------ Alterations and/or recommendations____________________ --------------------------------------------------------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------ ------------ ----------------------------------------- --------------- ------------ ------------------------ 1 1 � � V FINAL INSPECTION BY:_--------v . --------- ------- --------------------- Date------------1 ------------------------------ 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 E5-9-2M 8-51 Revised W-2100