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APPLICATION FOR i R SANITATION PERMIT Permit No. .- ---.___ (Complete in Duplicate) Y Date IssuedII _raS f* 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 O7nce No. 549. J --``r JOB ADDRESS D LOCATI ._I_--- - -T�-C- ----------------------------------------------------------- ---------------------------- -- t - Owner's Name- ----- --- ---- •- ------ Phone"-i lS.. Addres Contractor's Name-- -------- ------ - ----- -- ------------------ ---- Phone- ---- Installation will serve: Residence V/Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number.of living units: __ _ umber of bedrooms _--r___ Number of baths __Z Lot size _- _ _Q _/___X_ j� Water Supply: Public system [,►�Comrnunity system ❑ Private ❑ Depth to Water Table ---------ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam Clay Loam Clay Y y ❑ y ❑ Adobe �ardpan ❑ 1�+ Previous Application Made: Yes [ No ❑ New Construction: Yes 011 No ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s Se tic ank: Distance from nearest well---„ -____Distance from and iPn __----Material --__ - = p I - ----- No. of compartments------------- ------Size-/-z-- 4- X-----Liquid de t ---------------- - - - -Ca acit I Disposal Field: Distance from nearest well Distance from foundati n__-_� __--Distance to nearest to lin __ --- Number of.lines--------4__ 1t -______ Length of each line-_---- � � Width of trench____ _ __________Type of filter materi _ t _ -____ T ----- 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---------------------- ___--__ ❑ Size: Diameter---------------------- ------Depth-------------------------------------- -------------Liquid Capacity----------------------------9als. Privy: Distance from+ nearest well-----------------___-_----_--_--__---____---____Distance from nearest building------------------------------- -------- ❑ Distance to-nearest lot line Remodeling and/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, tate laws, and rules and regulations, of the San Joaquin Local Health District. (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 reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- DATE----`� ------------------ --------------------- --- ------------- -------------- --------- REVIEWED BY --- ----------------------------------------------------------------- ------ DATE---- BUILDINGPERMIT ISSUED ----- ------------------------- DATE.----------- ------------------------------------------- - ,e---------------------------------- Alterations and/or recommendations:-_----_--------------_----_ _- ------------------------------------------------------------------------------ ------------------------------------------------------------------------------ --•----------------••- -------•----•-------------------- ----------- ------------------------------- --- - FINAL INSPECTION BY-------------A/_V- ----------- Date--------- ------------� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfref 300 Wesf Oak Sfraef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100