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APPLICATION FOR SANITATION PERMIT �`�� Permit No, 15� ...... (Complete in Duplicate) Application is hereby made#o 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 ANQ OCATION_ � V .Ipog • Owner's Name-------- ---... Phone-------------------- Address �- -- - - • . ------------------------------------------------- Contractor's -------------- --Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ `Other ❑ Number of living units: _�____ Number of bedrooms _...Number of baths _ ___ Lot size --- ------------------------------- Water Supply: Public system (4 Community system ❑ Private ❑ Depth to Water Table ''] #. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam a Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No K New Construction: Yes Xj 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 fro oundon____ "� i .a /4..------.Mate�al----- ------- ---------- No. of compartments-----_-�----_------Size----- ----Liquid depth----- --------------------Capacity_. 0- Disposal Field: Distance from nearest weft- � _'{:Distance from foundation----/-- _.___._Dis#ante tp nearest lot line....... --_______ Number o{ lines...... Length of each Type of filter material-__5 ___ . Depth of filter material______ADO-_......... -------------------- Yp � - - Total length-- -- - - --------- ---------------- Seepage Pit: Distance to nearest well____________________ _Distance from foundation-------------------Distance to nearest lot line______-._____-.__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Deptn-----------------------------_ C Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material---___._-_________-___--__-__.__ _ -- ❑ Size: Diameter Depth ------------ ------------------Liquid Capacity--- -----------------------gals. Q Privy: Distance from nearest well-------_----------------------------.-----------Distance from nearest building-------------.------------------- ❑ Distance to nearest lot line---------------------- ------------------------------------------------ Remodeling and/or repairing (describe)-----------------------------------------------------• e ----------------------••-------•------------------------------------------•------------------------- --------------- ---------------•-----------------------•------------------------------------------------------------------------------------------------------------------------------- -- -------------- -----------------------------------------------------------------------------•-•-----•----------------------------•------------------------------•------•--------•-----------e--------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the,San Joaquin Local Health District. (Signed) ___(Owner and/or Contractor) BY --------------- -- --- (Title)---------- --------------------------------------------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F9 PAR ENT U ONLY APPLICATION ACCEPTED BY______ -_ -- .e -- ---- -- ----- --' - -- ------- ----------------- DATE------ --- --�:' - ---� ----------------- REVIEWEDBY------------------------------------- ------- -------------------------------------------------------------------------------- DATE BUILDING ------------ PERMIT ISSUED----•-------------------------------------------------------------------------------------- --------- DATE------ -------------------- - Alterations and/or recommendations------------------------------- ------------------------------------•--------------•------------------ ----•---------------------------•----.----------•-----------•------------ --------------.•-----------------------------------------------------------------•----------------------•------------ ..----:-------- --------------------------------•----------------- ---------------------------------------------------------------•------------------------------------------------ --- ----------------- ------------------•--------------------------------•---------------------------------------- ------------------------%----- ------------------------------------- FINAL INSPECTION BY-------------#.. ---- Date------ ------------------------------------ '" SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California MInteea, California Tracy, California ES-9-2M 10-52 Revised W-2100