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�00 l 5.4V1 gZlk APPLICATION FOR SANITATION PERMIT Permit No. ..: (Complete in Duplicate) -� -�.- Date Issued ___________ Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the w�rv�erein d cribed. This application is made in compliance with County Ordinance No. 549 JOB ADDRESS AND LO TION a `__C.. �-------------------------d - ��!`a--l/.C--------------------------------------------------*--------- Owner's Name Phone. -- s� - -- . Address" Gee .' 1 .......... ----- Contractor's Name............... - ....... --------------------------------------------------------------------------------------•-------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms ____L Number of baths __.__�_ Lot size ......... -------------------------------------------------- Water ____:___ ______________________________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 Adobe❑ Hardpan ❑ Previous Application Made: Yes F] No K New Construction: Yes jx No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if,public sewer is available within 200 feet.) Senkla Tank: Distance from nearest well-1-1047----Distance from foundation_..w/_,4........Material_______. ,,l -_' ... __ --------- (� No. of comparFments_-______:!err. __..__Size__ 9_)(__V--Liquid depth____!,_ ____________Capacity:____. :�_ _ Dis osal Field: Distance from nearest well_ _/Q-0_Distance from foundation _.Z--.Distance to nearest lot line +___ Number of lines__...........0 _-__ ___.. Length of each line_p2-� �.1�" 1/idth of trench 's- --�� ► Type of filter materiaL___�? epth of filter material-------- 91r_-Total length...,.....610--------------________•_ � 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_______________-__________________. ❑ Siza:'Diemeter•-------------- ..........Depth---------------------------------------------------Liquid Capacity - --_-;----- a Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-----------•_-..................I......... ❑ Distance to nearest lot line-------- --- -- ------ ------------- --- -------------- -•-------------_-- - - -------------------- .................. Remodelingand/or repairing (describe)-------------------------------------------------------------------------..............................................._.............----• ` --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•- •----------------------•------------- ------------ -------- -------------------------------- -------------------------------------------------•------------------ -------- ------------------------------------------- I - ------- ------------------ I herel�}r-certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc , State laws, and rules and r gulations of the San Joaquin Local Health District. (Signed) c - ---�---- ------------------- ---------- �''"�"' � (Owner and/or Contractor) ' (Plot plan, s g size o lot, locatio sys em in re ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE'ONLY APPLICATION ACCEPTED BY------------------------------------------------------ ........................................... DATE----------•- ---- ,.- REVIEWEDBY------------------------------------------------- --------------------------- ----------------- ------------------- DATE BUILDING PERMIT ISSUED......................................................... ----------------..----•-•--- DATE------------I--------------- Alterations and/or recommendations-------------------------------- - - -- ----•-----•--•----------------•-------•-•-•-•-•_--••---•••----•-------•----••.._..-•-•---------=- ---- ------- ----•-- -------• ------ -------- �� i ! - FINAL INSPECTION BY--- ------------- Date------------------------------ -:--------•-----•-------------------- 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 W-2100