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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ____ 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 No. 549. kv-C . JOB ADDRESS AND LOCATION_ --------—------------------------------------------ � ----------- ---- ------ 'e" Owner's Name----------------•----- J . � -------- ------- - Phone------------------------------------ Address---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ----------Address----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name---------------------------------- `-1/`L------------------------------------------------------------------------------------ Phone.---------------------------------- { Installation will serve: Residence C9 Apartment House ❑ Commercial ❑ Trailer Court [3. Motel ❑ Other ❑ I Number of living units: ___I____ Number of bedrooms ___L Number of baths _/_____ Lot size _________.._3_ _ = -4 __._______________ i Water Supply: Public system ❑ Community system ❑ Private N Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpa.n.❑ I 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----.--------------.____._._________._.._______- IINo. of compartments------ ------------- - ---Size--------------------------------Liquid depth-------------------------.Capacity-------------- -------- Disposal Field: Y Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line---.________._.__ ❑ Number of lines-----------------------------------Length of each line----------------------------..Width of french----------------------------------- Type of filter material_________________________Depth of filter material--------------..----.--Total length--------------------._-_________________._ Seepage Pit: Distance to nearest well__--------------------Distance from foundation___.................Distance to nearest lot line----------------- 3.- ❑ Number of pits---- Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------- {� Cesspo& Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________________.__.______ ❑ Size: Diameter------------------ ----------------- Depth----------------------------------------------------Liquid Capacity--- -------------- ---------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building_.______.______________________.__...._. i ❑ Distance to nearest lot line_________________________________________________ f Remode ing and/or repairing (descr el:__.- _(__ ----- ----- ------- rwr�---- - ------------ -- -- --------- - -- -- -- -- R ^r�� ` '� - -- ---------- ----- - r.. ---•--'---'-----`-- --""--------•----•------- -A -----------------------------------_----------------------------- ------------------ ---------------------------------------__.__.---•--------------------------------------»-------- I here y 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. Si ned --------_J- Owner and/or Contractor -------- -- --------------------------------------------------------- ----------------------------- --- ----------- _______ By:----------------------------------------------------------------------------------------------------------- -----------------------(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____________ _ _ <___ _r _ 'we— REVIEWEDBY------------------------------------------------------ --------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------------------------------------•---------------------------- DATE------------------------------------------------------------- Alterations and/or recommendationn+� ------------- -------------------------------------•-------------------------.------•----------------------- ---------------------------------�-�----- ------------------ '------------- ---------------------------------------------------------------------.------------------------ -------------------------------------------------- FINAL INSPECTION BY:..-- Date. `- - SAN JOAQUIN LOCAL HEALTH DISTRICTV 130 South American Streot 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 60-52 Revised W-2100 �f