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QN_ lit - Permit No- -------`--------- ,... y APPLICATION FOR SANITATION PERMIT (Complete in Dupcae] _�� Date Issued .__��_ :5�� S" Lam'•� 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. JOB-ADDRESS AND LOCATION- --_-- _ --------------------------------------------------------------------- Owner's Name - 1 � ------------------------ Phone �Z Address----------- --- d ------ -- - f � �� -- Phone---- . Contractor's Name_________________________ -~' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ ther ❑ Number of living units: _B____ ber of bedrooms _ ___ Number of baths _f_____ Lot size _________ J__a-/ ----- 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 ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ l TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is.available within 200 feet.) Septic Tqnk, ,Distance from nearest well-----------------Distance from foundation__-________-___-__.Material-------------------------------------------------- - ❑f�+` , No. of compartments ---------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal field: Distance from nearest well-________________Distance from foundation--------------------Distance to nearest lot line______-.-________ l E ❑ Number of lines-----------------------------------Length of each line_------------------------___.Width of trench----------------------------_------ + Type`of f ter material-------------------------Depth of filter material-----------------------Total length-_--------------------------�-------=•--- 0- ____Distance from foundation_ Di ice to nearest lot line_-________- 1 Seepage Pit: Distance to nearest well____ _______ _Linin material-----------------------Size: Diameter----. --------------Depth------ -_-_-- -_ -7 �' Number of pits____-_ g Cesspool- Distance from nearest well-----------------Distance from foundation-------------------lining material__________________________---._____-. � t Size: Diameter-----•--------------------------------Depth_----------------------------------------=--------Liquid Capacity-----------------------------gaIs. -•.. Privy: Distance from nearest well-------------------------------------------------Distance from ---------- ❑ Distance to nearest lot line------------- ------- -------------.-------- ---- -- --------------------- -- f ----------- Remodelingand/or repairing (describe):------------ -- --- ---- " --•- -- -- - ------------------ ---------•---------------------------------------------------._...---- L 1 ------------------------------------ ------------------------------------------ ---------•------------------------------------------------------------------------------------------------------------------------ ------------------------- •---------------- 1 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 rqzqulations of the San Joaquin Local Healt District. --------- (Signed)--- ------------ --- - - ------------------------- -------- O.ner an r Contractor) f� ~ -- ---t --- -- - --------------(Title)-- --- -- --- - - --------- (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY---- a'�`4: = DATE � ` -,.yf REVIEWEDBY------------- ---------------- -- - ------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMITISSUED------------------------------- ---------------------------------------------------------------------- DATE------------------------------------------------------------- Alteraticnsand/or recommendations-------------------- -------------------------- ------------------- -------------------------------------------------------------------------------------- h ---------------------------------------------------------------------------------------------------------------------------- ----------------------- ---------------------------------------------------- ---- --- ------- ---- ------------------ ------------------ ---------------- ---- ----- -- - --- -_ ---------------- -- --- ----------- ------ --------- --------------------- --------------------------------------------------------------------- --- ----- ---- ----- ----------- ------ -------------------------------- --------------- ----- FINAL INSPECTION BY:------------- _ _ �- _ -- --------------------- Date---------- f ---- ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100