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&-/ b l - APPLICATION FOR SANITATION PERMIT Permit No. __ _ (Complete in Duplicate) Date Issued .1 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. O ' V 30--(k JOB ADDRESS AND 4LOCATION--------------------- ----�-,, /- ------t- ---- ---------- --- - ------=f-- r-- ' m ;------------ Owner's Name---------------- -- -------- v*-� 6 - Phone �." Address------------------------------------------------•-••------------------------------------.------------------------------ -------------------------------------------.........-------------------------------- Contractor s Name ---------------------------------- Phone----------------------------------- Installation will serve: Residence U Apartment House ❑ TCommercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ----- Number of bedrooms ._�mber of baths I____ 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 ❑ AdobeM Hardpan ❑ Previous Application Made: Yes N No l] New Construction: Ye3�< No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: • • • , k " (No septic tank or cesspool permitted if public sewer is available within 200 feet.))} d Septic Tank: Distance from nearest wall�si_ _�_-.Distance from foundat-on___1_(�__ ^Material--. _ ______ _____ ______________ No. of compartments________ _______________Size__ ___. _ 'Liquid d ;Ih______--__/L___ _'_'_�__`CapacitY___ __ ____ � `� rJ- Disposal Field: Distance from nearest well--J�-��'�{.Distance from foundation______tp__'"�'.Distance to nearest lot line_- ---- Number __ _ c __--__-___Length of each line__ Width of trench_________ __ Number of lines----------2►.------ g ��-�-- �----- Type of filter material__-' +__ ___.Depth of filter rnaterial_____ ______:___Total length___________ __________ Seepage Pit:~ Distance to'nearest well----------------------Distance from foundation___--__________.-..Distance to nearest lot line__-____________ ❑ Number of pits----------------------Lining material_-_-, SDiameter ------------------ ize. -----------------------Depth-------------------------------- t � �1. Cesspool: Distance from nearest well------_----------Distance,.from foundation------------------- Lining material-------------------------------------- � ❑ Size: Diameter----- ------------------------------'Depth__ •------------------------- Liquid Capacity gals. Privy: Distance from nearest well_________________________ _ I------------ from nearest building_____-_______________________________-_- r ❑ Distance to nearest lot"line-------- ---------------------------------- -------------------------------------------------------------------------------- ------------ , Remodeling and/or repairing (describe):------------------------------------ --#-------l:------------------------------------------- -•--------------•-----------------------•--- 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 regulations of the San a uin Local Health District. m (Signed)------------------ - ------ ------ ---- ------- •-------------------------------------------------------------(Owner and/or Contractor) j By----------- --- - --- --- -- ---------- -- ------------- ---- -----------------------------------------------(Title)---------=--•-------------------------------------------------- (Plot plan, shows a of lot, Iota+' n of syste relatio to wells, buildings, etc., can be placed on reverse side). IF- FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY------- ------------� -----------------------` DATE_... . - -`S REVIEWEDBY----------------------------------- ---- - -----------.---------------------------------------------------------- --------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------- -----------------I-------------------------------------------------- DATE----------------------------------------------------•-------- Alterationsand/or recommendations:----}------------- ------------------=--------------•------------•-------------------_-•-------•-••---------•--- ---------•-----•-••--•------•---_--------- ---------------------------------- --- ----------•-------------------•---------------•---------------------------------------------------------------------------•-•-----•------------------------------------------------- f - -------------- e - - ------------------------ -------------------------•---- ---- " 2 FINALINSPECTION BY:_-_--------------�SA----------------------•---------------- --Date-_--------------- ----------—------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Horth "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Pl;-9—?M I ' Revised W-2100 1�1