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APPLICATION FOR SANITATION PERMIT Permit No4-_ (a,J • (Complete in Duplicate) Date Issued r 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 t aa -- - --------------- --------------------------- ------------------------------- JOB ADDRESS A D LOCATION,_)--------- - Owner's Name - Phone ----- t ----------------- - ---------------- -- ---------•--- -----------------•------------------------------•----------------------- -------- ----- ----- - --- Contractor's Name-_ {-----------•------------------------------------- P one------------------------•---------- - ---------------- Installation will serve: Residence ❑ R Apartment House ❑ ,Commercial ❑ Trailer Court ❑ Motel Other E3Number of living units: ._- --- Number of bedrooms Number of baths .✓ of size -------- -I.— Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �Hardpan EJ A Previous Application Made: Yes El N3 New Construction: Yes f' TYPE OF INSTALLATION AND SPECIFICATIONS: WI (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material _---- ❑ 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------------------.-----. Type of filter material-------------------------Depth of filter material--- Total length--------------------- ._--- ----_.-_----___ .--_ S epa e Pit: Distance to nearest well.. 11 "_,C Distance from,foundation_ / Distano nearest lot e-_--!(/ Number of pits-- f-------------Lining material_ - _ - -_ r Dia d1'r__. --- �� ----.Depth------- ---�------ Cesspool: Distance from ne-rest well-----------------Distance from foundation__.----------------Lining material--------_------_ ❑ Size: Diameter------ ---- ------------------- ------Depth--------------------------------------------------:-Li Liquid Capacity q p tY gI Privy: Distance from nearest well-------------------------------------------------Distance from nearest buiVri g ----❑ -Distance to nearest lot line----- -- ------------------------------------------------------------------------------------ `r Remodeling and/or repairing (describe):------------------------------ ----------- ----------- - -- --------------------------------------------------------------•---------------------------- -------lhrel:iy ----------------------------•-------------------.--------------•------------------------------------------------------------------------------------------------------------------------------------------- I 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. (Signed)------ B � ✓� �f� O� r - -- (Owner and/or Contractor) --I -----------------------------------------------(Title)------------------------ -(Plot plan, showing ' e of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i —FO R DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY------------- ------------ - - =------------------------------------------------------ DATE---------- ---- --------•-- -- REVIEWEDBY------------------------------------------------------------------------------- ----- DATE BUILDING PERMIT ISSUED------------------ ------------ ------------ --------------- -------- DATE---------------------------- ------------------------------- Alterations and/or recommendations:------------------------------ ---------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- 1 -------------------------------------- -------------------------------------------- FINAL INSPECTION BY------..--- I - ------------------------ ---------------------- Date ! - ----------------- SAN ---------- -SAN JOAQUIN LOCAL.HEALTH DISTRICT 130 South American Street 300 West Oak S+reef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised.W-2100