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el � 1D� APPLICATION FOR SANITATION PERMIT Permit No. ti t 4Com lete in Duplicate)(Complete p P ) Date issued NApplication is herehereby made to the San Joaquin Local Health District for a permit to construct a d install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------- --- Owner's 1 n Name - S " .= 1Ar ------------------------------------------ Phone-------------------------------- r Address------------------------- " ' " Contractor's Name---------------------------- Phone----------------------------------- ------------------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ I! Number of living units: •--_____ Number of bedrooms -9--- Number of baths _ ______ Lot size & � s-s _____________ - --- ------------------------- Water Supply: Public system 5Y-Communify system ❑ Private ❑ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0—Hardpan ❑ Previous Application Made: Yes ❑ No [I?"' New Construction: Yes ET'-No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan Distance from nearest well------ f____Distance from foundation___ ________.Material___-f __--------- __________ No. of compartments---------_`z-----------Size---3n: ---Liquid depth------- -- -____--Capacity----- Disposal Fi Distance from nearest well-------------.Distance from foundation-----/ ---------Distance to nearest lot line----!5- -Ilk _r__._ Number of lines_____________�_h--P-___�__Length of each line_-----------_�________- __.Width of trench__--_---_--- Type of filter material__ _______" Depth of filter m'aterial__________1e---!--Total length________________1�Q__�____________ Q Seepage Pit: Distance to nearest weft----------------------Distance from foundation-------------------.Distance to nearest fot�line_________________ ❑ Number of pits-----------------------Lining material-----------------------Size: Diameter------------------------Depth-------------------_------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____---______________________-_____-. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------_Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building - �❑ 4 - Distance to nearest lot line_______________`________ --------- ------ - Remodelingand/or repairing (describe)-----------------------------------------------------------------=---------------------•-------------------------------•-------------------------------- --•-----------------------------------------------------------•----•---..----------------------____----------•-------------------------------------•---------------------------------•-------------------------------------- ------------- -------------------------------- ------------------------------------------------------------------------------------------ ------------------------------- � 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 Joaquin Local Health District. (Signed)-/- ------------------------ ----------------(Owner and/or Contractor By:---------------------•---------------------------------------------------------------------------------------=--------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------- -------- --- ------------------------------------------- DATE-- REVIEWED BY--------------------------------------------------- ----------------------------------------------------------------------- DATE_ - BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations--------------------------------------- -------- ------- ------------------------------------------------------------ - ---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ ----------------- -----------------------------------•--------------------------------------------------------------------------------------------------------------------------------•-•----------------------------------•----------------•--- ----------------------------------------------------------------------------------------------------------- ---------------------------------------------•-------------------- ------------------------------------------- ------------------------1-1------------------------------------------------ ----- ---------------------------- -------------------•---------------------------------------------------------------------------------------- FINAL INSPECTION BY------------- -- ----------- ------ Date---------------- --- ,7 SAN JOAQUIN LOCAL HEALTH DISTRICT { 130 South American S+roof 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