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APPLICATION FOR SANITATION PERMIT Permit No. 40.a-. a (Complete in Duplicate) .r Date Issued ___.- _ C � � 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 . 549. U� JOB ADDRESS AND L Tl N------` . ; - - j v� 6 -- ----r------ Phone Owner's Name----------- - Address-------- .�---�---=�------------------- ------------------------_ -- --- --`�--------------------- Contractor's Name-----------------_- FF ----------------------------------------------------- Phone----------------------------------- Installation will serve: Residence er-Apartment House [-] Commercial E] Trailer Court ElMMotel ElOther El Number of living units: -1- Number of bedrooms,- Number of baths ---/-- Lot size ____'!"j/��'-c-Y �--"--'-_ Water Supply: Public system ❑ Community system ❑ Private JE 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 ❑ No New Construction: Yes ❑ No [� 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________________Distance from foundation------------------.Material_.._-_-_--------__.-____-_-.______.._______-_-. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---------:----------------Capacity----------------------- Disposal Field: Distance from nearest well--- Distance from foundation______ ____.Distance to nearest Iodine_-__ Number of lines_____--._____d _________fLeng Length of each line___-__-___. ' �-----.W+dth of trench____.._- �� ---------- Type or filter materiaDepth of filter material--- ( ------Total length------------ -___--- O 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_____________________________________________ ___Distance from nearest building- ___.______-.--______________---_____-- ❑ Distance to nearest lot line---------------------------------------------- ------------------------------- ------------------------------------------- •----------- Remodeling and/or repairing (describe):------- ------------ o Gc Y C� R. )l�f i I l •r r-�-----•-----I---r---y-----------------��------ �------------------- T�' -' C1VV A-------------------------- - - -------------------------------------------- -------------------------•-----------•--------------------------------------------------- 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 San Joaquin Local Health District. (Signed)-------- --------------------- --------------------------------------------------------------------------------------(Owner and/or Contractor) ------------------ Title By:__- ts �� "� = C1>A ----------------------------------------------------------------------------- -{ )---------------------------------------------------------------- (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------ --------- -- v------------ DATE------- ` S� - -------- --- --- --------------------------- REVIEWED BY------------------------------------------------ --- ----------- ------ -------------- DATE----------------------------------------------------------- -- BUILDINGPERMIT ISSUED--------------------------------- ------------------------------------------------------------------- DATE------------------------------------------------------___ Alterationsand/or recommendations--- -------------------------------------------------------------------------------------------------------•--------------------------------------------- --------------------------------••---------------•------------------------------------ .............------------- ----------I-----------------------------------------------------------------------•----------- ------------------------- ----------------------------------------,-------------•-------•--------------------------------------- ------------------ ------------•-------- ----------------------------------------------------- --------------------------------------------------------- ---------------------------------- --------------- ----------- ------------------------------- ------------------------------ -------------------------- -------------- FINAL --------------- --F1NAL 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 10-52 Revised W-2100