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r �h __`5 APPLICATION FOR SANITATION PERMIT Permit No. --.-�� (Complete in Duplicate) Date issued _____ Applica{ion is hereby (made toe 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. I � ----------------------------------- -------------------- JOB ADDRESS AND LOCATI --- ------- ----- IPhone------------ ---------------------- -- -------- y Owners Name------------- - - Ad d ress-------_------- ( ( ------••-----------""---------------------------- Contractor's Name-------------------------------------- ----- - - --------"-------- Phone.. o silence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ °Other p- 5 - X ---- installation will serve: Rei „ ,�- Number of bedrooms :�-- Number of baths .__ ----•-----'-' Number of living units: �__ Lot size _______ Water Supply: Public system Community system❑ Private ❑ Depth to Water Table ------- f+. a Character of soil to a depth of 3 feet:I Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Kg--Hardpan ❑ Previous Application Made: Yes ❑t ,No ew Construction:' Yes g--Tqo ❑ TYPE'OF INSTALLATION AND SPECIFICATIONS: (No septic tan0or cesspool permitted if public sewer is available,within 200 feet,) a Septic Tank: Distance from nearest well_____.__-____=__Distance from foundation_____________'.__.Materia__._______:___-________-._______________-__"__. 171 No. of compartments------ ---- Size------• ----------•-- Liquid depth 'Capacity Disposal Field: Distance-from nearest well--------------- -Distance from foundation--------------_____.Distance to nearest lot line_______"._______. Number. of.lines-----=---------------- ------Length of each line---------- -------- ---------Width of trench------------------- --------------- �- De th'of filter material----------- ------Total length-- of filter material_".___"_______________ __ p , Seepage Pit: .Distance to nearest we Seepage from foundafiion____..______.______.Distance to nearest of me__.____-.______._ -------Size: Diameter------------------- Depth Lining material. �PNurriber of pits_ . _--____"-_- _-- _ ! . Cesspool: Distance from nearest well=_______-___-_€Distance from foundation_____________°_---Lining materia__"____.________.---- ------"_als. ❑ Size: Diameter_ i- I Privy: =DDeppth-----------------------------------------------------Liquid Capacity---------;J---- 9 Distance from 'nearest _______ t well ________-- ------------ Q-------_Distance from =nearest building._:_" --------------------------------------------------------------- ---- Distance to'nearest:latline---------------- _ - Remodeling and/or repairing (desclibe):----------------- ---- ------- -- ---•--------------------•------•----••-------------------..------------------------------------------------------- ------------ -------------------------------- -- ------ ----------------------------------•------------------------------- _ ___41_.. I hereby certify that l have-prepared this application and that the work will be done in accordance with San Joaquin County ordinance State laws and rules and reg lations of the San Joaquin Local Health District. t t y ----------------------------- ------ '----------------------(Owner and/or Contractor] [Signed ----- $r _ . -=----------=------------------------------------------------(Tits e)_ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side}. � i - _ FOR DEPARTMENT USE ONLY' r - DATE_--------____ /"-� --- APPLICATION ACCEPTED BY___________-_-___----" _ -- -- - -- = ----- DATE--- ---•-------- REVIEWEDBY---------------------------------"------- -----------------------------------:------------------------------ -------------------------------------- ---------- ------ DATE---------------------- -------- BUILDING PERMIT ISSUED-------------------r--------- ---------------------------------------------- --------- - Alterations and/or recommendations_--------------------- ----------- _-_-_ __ -------•---------------- - ------------------ ------------------------ •------- FINAL INSPECTION BY:_-_-"------------------- - - - _-- "` ----------------------------------- Date-...SAN JOAQUIN LOCAL HEALTH DISTRICT 1300 West Oak Street 132 Sycamore Street 814 North "C" Street 13o South American Street i Tracy, California Stockton, California Lodi, California Manteca, California Y ES-4-2M ; Revised W-2100