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APPLICATION FOR SANITATION PERMIT Permit No./d- _____ (Complete in Duplicate) J Date Issue,,/_0/_1_V-- Application is hereby made to the San'Joaquin Local Health District for a permit fo construct and install the work herei escribed. This application is made-in compliance with County Ordinance No. 549. . J / JOB ADDRESS AND LOCATI N.---•-_------ '�� `� �'$-- - - - ---------------------------------------------------------------------------- Owner's Name---------------•----------- -------- -- = ---------------------------------------------------------- Phone------------------------•----- Address.........................................................------------------------------------------------------------------------------------------------ Contractor's Name---------------------- ------- ----`----------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence E&,,K'partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: __l____ Number of bedrooms -2---Number of baths Lot size -------67 X---1 V_ ___________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. V Character of soil to a depth of 3 feet:r Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes to ❑ New Construction: Yes 0- TYPE OF INSTALLATION AND SPECIFICATIONS: (No.septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_ Distan from fou .ation____�_!�________.Mate iai_______________ _________ ___ ---------- be __�6�: �f ---------Size-- No. of compartments______a�fF __ __ _____Liquid depth_____________________Capacity___ ___Disposal Field: Distance from nearest we __��'h�Mstance from foundation___1.0_4-______Distance to nearest lot line__ ---- ___ Number of lines________________ _______?Length of __ -(i_.Width of trench------- -- -----� --- Type of filter material____ '__.__ Depth of filter materiaL____1-2--________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 --gals. Privy: Distance from nearest well-------------------------------------- _----------D0-an, rat m neaiesf"building` ❑ Distance to nearest lot line-- ------------------------------------------------------------------------------------------------------------------------------------------- r Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------ -------------------------------------- i ------------------- 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 regulations of the S Joaquin Local Health District. i itP . / {Signed} ----- ---- ----- t'~ (Owner and/or Contractor) R =----- ------------------------------------------- --------------------------------------(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------------ A ---------------- REVIEWEDBY----------------------------------- ------------------------------------- ------------------------------------------------ DATE------------------ --------------- ------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:------------------------------------------------------------------------------------------------------•--------••--------------------------------------------- ------------------- a -----------------------•------------------__------------------------------,n-�-------------------------------------------------------- ------------------------------•---------------------------------------- ------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------ ---------------------------------------------- d -------•------------------------ ---------------------------------------—----- FINAL INSPECTION BY:------/ --------------------------------------- Date------------1 ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Sout{, American Street 300 West Oak Street 132 Sycamore Sfreef 814 Norfk "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 SIC