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,. APPLICATION FOR SANITATION PERMIT Permit No. -5 7_ ---...... (Complete in Duplicate) Date Issued ____-_7 Ns .- 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 wit County O nance No. 549. JOB ADDRESS AND LOCATI N__ . Owner's Name --------------------------------- --------- ---------------------------------- --------- Phone------- ---------------- Address------- .- -- ----- ------ Contractor's ----Contractor's Name---- ----= -- ---- -• ----------•---------------------------------------------------------------------------------- ------- --- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ M ,tel ❑ Other ❑ Number of living units: -_/--_ �3mber of bedrooms _- - Number of baths --�---- Lot size ---/- -- -- -------- ------------------------------ Water Supply: Public system [Community system ❑ Private ❑ 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 ublic sew"r is available within 200 feet.) Septic ank: Distance from nearest well _-�I- istan er fro 'found0or/0---.- -------- ater•al!- ` __.-_-. _. - -__--- ------- --- Capacity -- No. of cornpartments-----.. -- - .__.-.--Size- x- __�`� S-_Liquid e tip- Ca acit P p Y------- -- ;, Dispos Field: Distance from nearest well__ ... !Distance from foundation-ff�_ istance to nearest lot li it 4� , __ en th-�of each line------------ Width of trench--__-__- . ----- -__----- Number of lines-----------�--- _ _-_-- g ( - -- -- -- r� , Type of filter materit �Q�pth'of filter material_------- -- - ------Total length----------l_ A ------------------ Seepage Pit: A Distanee'fo nearest well____ _____________ Di,stance from foundation-------------------.Distance to nearest lot line----------------- ❑ Number of'pits-------------------(-Lining material--=-----_-----------Size: Diameter_.-------------------Depth--------------------------------- Cesspool: Distance from nearest well----------------- from foundation---------------------Lining material___----------..----..---.---------. ❑ Size: Diameter--------------------------------------Depth---------------------•------------------------------Liquid Capacity;---------------------------gals. Privy: ','Distance from nearest well-------------------------------------------------Distance from nearest building------_.-------_-----_.__----------.-.:.- ❑ Distance to nearest lot line------------------------------ ------------------------------------------------ Remodelingand/or repairing (describe)----------=--------------------------------------------------------------------------------------•-------------------------------------------------------- p -----•---------------------------- _---------_--------------------------------- g ---•---------••------------------------------------------------------------------------------------------------------------------------------------- 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 re ulations.of the San Joaquin Local Health District. I {Si ned g ------ -------------------------------------------------------------------------------------------(Owner and/or Contractor) I � t 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 13Y- -- . - 7 ------ DATE_ REVIEWEDBY----------- ED ------- ------------------------------------------------------------------------------- DATE- BUILDING PERMIT ISSU --------------------------------------------------------------------------------------------------- DATE.--- Alterations and/or recommendations--- ---------------------- ----------------------------------------------------- -------------------- -----ls�—'-------- -------- ----------------------------------- -------------•-----------------I-----------------------•-•------•------------------------I-------------------------------------------------- ----- -------------------------- ---------------------------------- - -----------------------------------------•------- ------------------------------------------------------------------------------ --- ------------------------------------- -------- FINAL INSPECTION BY:..i� ---- Date....-- - �� f� I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M j4-52 Revised W-2100