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h APPLICATION FOR SANITATION PERMIT Permit No. (Coinplefe in Duplicate) , -------- Date Issued _l__ _ Applica+ion 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. w _ JOB ADDRESS AND L ATION ,/,� ---- - -------- ---- --- -------'__ _._.. - � /---------------------- Owner's Name-- ----- ------ -- Phone- ---`+r_'-- Address_____ I -------- - -- ---------- -= -------------------------- � -� ---- ------------------------------------------------•...-----.------- ------------ Contractor's Name Name •- ------ ---- Phone_ --- ------ lnstallafion will serve: Residence ❑ Apartment ouse ❑ Commercial ❑ Tr�pil r Qo rf ❑ Motel ❑ Other ,$f Number of living units: Number of bedrooms .z,� Number of baths . -_ __ Lo size Wafer Supply: Pubiic system Community system ❑ Private ❑ Depth to Water Tablet 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 DT No ❑ TYPE OF INSTALLATION AND SPECdlCATIONS: (No septic tank`or cesspool permitted if public sewer is available within 200 feet.) r..- p y Septic T k: Distance from nearer} well-----------------Distance from foundation--------------------Material--____________________-__--_____________--____. No. of compartments-------------------------Size-------------------------------Liquid depth--------- ----- - --------Capacity---------------------- Dispos Fie Distance from nearest welt_________________Distance from foundation----------------.---Distance to nearest lot line------- ...______. � Number of lines--I--------------------------------Length of-each line------------------------_----.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------------Total length--'.------------------------ _---------- See a e Pit: Distance to nearest well-- Distance rom fo dation______ Distance to nearest lot line____ Number of pits---! -------------Lining material--Size: Diameter----1i ------Depth-� - Cesspool: Distance from nearest well-----------------Distance from foundation-----------.---.-.--.Lining material.------------------------------------- El .-_______________._____-_____ _❑ Size: Diameter- --------- -----------Depth ---- -•-- ------ - -------Liquid Capacity-.--------------------------gals. Pnvy: Distancefrom e'Aa esf well "'----------- - -A~`pisfance'fromnearest`building.____..._ ---------------------- -- ❑ Distance to nearest lot line-------------------------------------- ----------------------------- ---------- . Remodeling and/or repairing (describe):---------- A_ ---- ------------------- .. �.�- ------- -------------------•--------------•------------ ---------------- ----- ------------------------------ ----------------------------------------.--------------------------------------------------------------------------------------------------------------•.-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfaf aws,'an rules and regulat' f the San Joaquin Local Health District. i r�(Signed)---------- -- - ----- Owner and/or Contractor] By:--------------------------- s �/ ' ,---------------------------------------------------•----------•------- Title (Plot plan, showing size o of, locatio' of system in relation to wells, buildings, etc., can be p on reverse side). { FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------I----- ----------------------------------------------- DATE------ t� REVIEWED BY----------------------------- ------- - - ------ DATE------- -- - ------ BUILDING PERMIT ISSUED------------------------------- --------------------------•------- ��------------------ DATE-------------- Alterations and/or recommendations----------- ------- --------- --- ------------------------------------------ ---------------•-.•-------------------•-------•------- _ . -•---•---------------•------------------------------------------------------------------------------------------------------------.-...---------------------------------------...---------- ------------------------ s... I FINAL 'INSPECTION BY----------------- ---------------------------------------------- Date-----------------q----., - V" ---•----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M i Revised W-2100