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APPLICATION FOR SANITATION PERMIT Permit No. - _______-_ 1 (Complete in Duplicate) y �p Date Issued -l- -dS Vk pplic ion is hereby made to the San Joaquin Local Health District for a permit to constru and install the work herein described. his application is made in compliance with County Ordinance No. 549 JOB ADDRESS AND OCATiON ®--------- .. .... ------------------•---------•-•-------------/--y-----•------------ Owner's YNam?- _- - ----•---•--- - -- C - - -------------------------------------------- Phone------ Address... Address-•- --• + - r ------------------ f Contractor's Name------------- �� y --------------- --•---- Phone 1 Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: j--- Number of bedrooms___ Number of baths j- Lot size _ 4 '_,�.?�0________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table—YO- ft. Character of soil to a depth of 3 feet: -Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado Hardpan E]Previous Application Made:; Yes ❑ No Oe New Construction:, Yes , No ❑ TYPEtOF INSTALLATION AND SPEC INCATIONS: (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--------------------------------Li uid de th__-___-_____---_-_ _-Ca acit Y Disposal Field — Qistance frbm,nearest well------------------Distance from foundation--------------------Distance to nearest lot line_---__-____-_____ y Number oi. lines------%---------------_- ---------Length of each line------------------------------Width of trench---------------------------------- C TYPe of filter material-------------------------Depth of filter material----,--- -----Total length------------------------------------------ Seepa e Pit: Distance to nearest'well___- ______._D+stance f m fou ation--- ___...Distence to nearest loft line__- -___.- Number of. pits Lining materia�� Size: Qismeter---.-: Depth ' -------------------- !* Cesspool: Distance fi bin"nearest well------------------Distance from foundation--------------------Lining material-------------------------------------- c ti -_____Li Liquid Capacity _ gals, ❑ Size: Diametelr---------------------------� - - Depth - ------------------------------------------ q P Y------------------ - - Privy: Distance fromxnearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line-- ----- - ------------- ------------------------------•-•-------••---------------------------------------------------- ------------------ Remodeling and/cr repairing'(cl ribe)--------------- ---- /----- ------------------..................•.. 11-----------------I------------------------------------................. " --•••-•------------------------- -------•--------•--- - ------------- +r 1 ----------------•--------------------------------•------ -- --------------•------------------------------------------------------------------------------ --------------------------------•---------------------- -------- . I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat s, and r sad regulations of the San Joaquin Local Health District. __ !_ -- Owner dor Contractor (Signed) { .� I By-...--- ; _ -----------------------------------------------•---------------------------------------(Title) � �'�------- (Plot plan, showing size o of, location of system in relation to wells, buildings, etc., can be pl ed on reverse side w FOR DEPARTMENT USE ONLY ' APPLICATION'ACCEPTED BY--------- ----------------------- - - - ------•--------------••------------------- DATE.---------- - REVIEWEDBY--------------------------------------------------------------------- -------- -------------------------------------------- DATE-------------�`_�---5----�------•---- ------ BUILDINGPERMIT ISSUED----------------------------------------------- ---------------------------------------- DATE-------------------------------------------- - --- ---- Alterationsand/or recommendations:----------:---------------------------------------------------------------------------------------------•------------------•------------------------------ --------------------------------------•----------------------------•------------------------------------------------------------------------------------------------------------------ ---•----------------------------------- - -------------------------------------- ----------------- --------------- ------------------------------------------------------------ ------------------------------ ------------•-------•---------•--- ----------------------------------------------------------•------------------------------------------------------------------------------------ 5 FINAL INSPECTION BY: � - --------------- Date - - - `y' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reot 300 West Oak Street 132 Sycamore Street 814 Nor+h "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100