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APPLICATION FOR SANITATION PERMIT Permit No. .0.. ._ (Complete in Duplicate) - Gate Issuedl-�__`_�_. _.___.___ 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 Ordinances ,N�o[. 549. g'� JOB ADDRESS AND �QCATION-------- ~_ {�M- �!1_j '_________.___ ------------------------------------------•------•----•--------- Owner's Name.. = Phone ''"- � Address---------------------� ` Contractor's Name---------- _ -------------•-------- --------------------------------------- ------------------------------------- Phone---- ------------�`_� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/------ Number of bedrooms ---/_ Number of baths __/___ Lot size --------- -- _i __ ________________ Water Supply: Public system �K Community system ❑ Private ❑ Depth to Water Table ________ ft. _ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobejk Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No. ',M 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 foundatio n_---------._.____.Ma#erial--------------------------------------- .____•___- ❑ No. of compartments--------------------------Size--------------------------- ---Liquid, depth---------------- -----Capacity--------------•-------- Disposal Field: Distance from nearest well----'°'----------Distance from f undation--------------------Distance to nearest lot line_--_.--_________ ❑ Number of lines-----------------------------------Length of a line------------------------------Width of trench-------------------------,-------_-- Type of filter material-------------------------Depth of i ter material-----------------------Total length--_-_-_-_________-__________----_--.---__ Seepage Pit: Distance to nearest well----------------------Dista e from foundation--------------------Distance to nearest lot line______-__________ ❑ Number of pits----------------------Lining mate ial-----------------------Size: Diameter------------------------Dept h---------------------------_---- Cesspool: Distance from near st well_- t_ � tance from foundation-----�6----------- material----- ` :Size: Diameter_--__ Depth___-_________- ------------------------__ Liquid Capacity-.- 5_0----_______ ale. . Privy: Distance from nearest well----___ _:____________________________________Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line__ . I Remodeling and/or repairing (describe):___---_------- Yf -----------------------•----------------------------------- --------------------------------•--------------------------•------------------------------------ -- --------------------------------- •------------ •--------------- -------------------------------------------------------------------------------------•--------------------------------------------------------------- -----------------------------=---------------------------- --------------------------------------------------------------------•--------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and rules arfd regulations of the San Joaquin Local Health District. �- - (Signed)------ ------ ----- - -- ----- ----- ----------------------------------------------------------------------------- (Owner and/or Contractor) By: (Title)_ ----------------------------------------------- --------------------------------------------------------------- (Plot plan, showing size of I , location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- -- --- - ------ ------ ---------------------------------- DATE--- } REViEWEDBY-------------------------------------------"--r--_---------------------------'�--=---------------------- --- ------- DATE---- -------------------------------- BUILDING BUILDING PERMIT ISSUED----------------------------------------- -------------- -------- DATE-------------------- . ----------------------------------- ----------- ----------------------- - Alterations and/or ecom endations________ __ _ __ _ - --- - �� /,- '.. /tl f---- - '---------------------------------------------------- -------------------------- -------------------------------------------------------------------------------- -------------------------- ---- ---------------=---------------------- ------- �, ---------------------------- ------------------------------ ------j''�—'�!T, --------/ - ----------------------------------------------------------------- FINAL INSPECTION BY: -- ` Date ------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 3oo West Oak Street 132 Sycamore Street 814 North "C" Sfreat Stockton, California Lodi, California Manteca, California Tracy, California in$---9---2M 8-51 Revised W-2100 1'�