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a�tol o Ga(Lecf yZ �� APPLICATION FOR SANITATION PERMIT Permit No. -Z..� (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 LOCATION + Owner's Name------ ------ -- --- -------- --------------- --------------- --------------- Phone---------------------- ........... Address-------1 --- ---7•----- . ----•- - - -------------- '-------- - Contractor's Name------ - - ---- ------ -------------- -- ------------------------- -------------------------------------------------------- Phone----------------------------------- Installation will serve: Resid nce 0' Apartment use ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .1---- Number of bedrooms ---!--- Number of baths ---I--- Lot size ____„ ___________________________ Water Supply: Public system ❑ Community system k Private ❑ Depth to Water Table JmT ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay X Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes P No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public e r is vailable within 200 feet.) Septic Tank: Distance from nearest well --- anc e from founds ion_....`. – __..,Mlat rial_________________________________�y__._ No. of compartments__ --------------- - 'ze... _ Liquid /depth__�,�V____-_Capacity---____�C_ Disposal Field: Distance from nearest well_ sante from foundati n__7! .r____._.Distance to nearest lot I' e- ---- _- Number of lines_._y_______ _______ Length of each line-.__ . -—T-y_.Width of trench Type of filter material____?'a .depth of filter material_._j_�«_________Total length-_____ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- F Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Dept h--_-__.____-__-_________________- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______________________--_-_-___-__. ❑ Size: Diameter------------------------- ------Depth---------•-•--•-------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building_____:_____________-------____-____.__. ❑ Distance to nearest lot line-----------------------------------------------------------------------------------------------•---•---------------------------------------- Remodeling and/or repairing (describe):--------- ------------------------------------------------------------------------ ------------------------------ •------- W ---------------------------------•------•-------------•-------------------------------------------------------------------------------------------------------•--•-•---------------------•--------------_------------------- Q ---------------------•-----•-•-------- ---•------------------------=----------------------------------------------------------------------------------------------------------------------•-•------------------------------- ----------------------------------------•-•-----------------------------------------------------------------------------•----------------•-------------------•------•------------•-------------•---------•--••---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State libws, and rules and regulations of the San Joaquin Local Health District. (Signed)_ -'.. (Owner and/or Contractor) By:--------------------------------------------------------------------------------------- -----------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, I cation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ----- DATE...-- . _ ----------------- - ------------------------------ REVIEWED - - - - --------- ------------------------ -- REVIEWED BY -------------------------------------- DATE--- - --- ------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE----------------------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------......... ----------------------------------------------------••-----------11-11-------------------------- ----------- ------------------------- -------------------•--------•--------------------------------------------------------------------------------------------------------------------------------- --------------------- ------------------- ------ -•------ -------------------------------- -------------------------------------------------------------- ----------------- FINAL INSPECTION BY--------------- -----•------------------ Date--------(/_-_•--Y---�------------------------------------- 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 ES-9-2M Revised 1.57 F.P.CO.