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I I APPLICATION FOR SANITATION PERMIT Permit No. --------/---------- (Complete in Duplicate)ple Date issued _______ Applica-'ion 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. JOB ADDRESS AND LQCATION------- - ----------�-f•-- ....... --------------------------------------------------- �f ----------------------•------ ------------------- Owner's Nam ----- _'�, ------�� -------- ---------- ------ --------------------;----------- Phone_ -.. -2-----�7-,�^ Address- -- - -- ._.. ---------- ----------------------------------------- ------------------- Contractor's Name---------- ---- ? t- -- - ------- Phone-- Installation will will serve: Residence Apartment House ❑ Commercial ❑ T i er Court ❑ Motel ❑ Other ❑ Number of living units: umber of bedrooms_. Number of baths /. Lot size _- ___ Water Supply: Public system ❑ Community system ❑ Private/K Depth to Water Tablesft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobefY Hardpan ❑ Previous Application Made: Yes ❑ NoA 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____. _______.Mat^er'al_C .--�______ ________________________ No. of compartments__- -------------___Size_ _, .t1-_ --.Liquid depth_ _` "- ------Capacity---- ' ------ Disposal Field: Distance from nearest well Distance from foundation -- ______-Distance to nearest lot line._-- ----------- Number ----.- Number of lines_______ ______________ Length of each line-------_�_Q_ _____._.Width of french_____.. _ ____..____________ Type of filter materia______Depth of filter material___ .............Total length____-__,��_______________________ Seepage Pit: Distance to nearest well.._.__�Q--_____DistaInflation______F_....___.Distance to nearest lot line____:��___ Number of pits__._______________Lining ma eria��11,,__ _ Size: Diameter_ ��_��_..____Depth----..� _________________ w Cesspool: Distance from nearest well-________________Dis afounclafion--------------------Lining material______.____________-.-___________--_. ❑ Size: Diameter--------------------------------------Depth---------------- -----------------------------------Liquid Capacity---------i------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------__-- ___-_____________.____._- ❑ Distance to nearest lot line------------------------------------------------- ------ I Remodeling and/or repairing ------------------- ---------------------------- I -------------------------------•---•----------------------------------------•--------------------------•-------------------------•--------•----------------------------------------------------------------- -------------------------------------------------------.--------------------------------------------------------------------------------------------------- •--------------- ------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--- - 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 r�,'onsf the San Joaquin Local Health District.(Signed)----------- (Owner and/or Contractor------------ ---- ------ ---------------- ---(Owner t � s----------------------------------------------------------------------------------(Title.- - ------- (Plot -----(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be p ced on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------- ----------------------- DATE--------------- - '- ----- ---------------------- --------- REVIEWEDBY---------------------------------------------- ---------------------------------------------------------------------------- DATE-------------- --------------- ------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------•------------ DATE-------------------------------- --------------------------- Alterationsand/or recommendations:--------------------------------------------- - -----------------------------------------------....-----•------------------------------------------------------ ----------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- r �� - .5-y- _INSPECTION BY-------- ------- ------------ z� Date SAN JOAQVIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100 S t