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f��,;e� > p �"� APPLICATION FOR SANITATION PERMIT trPermittiNo. _ �J_______________ (Complete in Duplicate) ppI s Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. {B ADDRESS AND LOCATI y Ordinance No. 549. JOB app cation is made in compliance w� ount------------ - --- ----�� . �- .._ ^_� --- -- - -------------------- Owner's Name-.-� -= ----•- ----------- Phone----- Address-......... ---Address---------- s---------------•-- ---- -- ------------------- --------------------------------------------------------------------------------------------- --_------------------- Contractor's Name------------- - ---- - ------------- -- - ------ ---------------- -------------------------------------------------------- Phone--------- `._.------ i Installation will serve: Reside e Apartmen ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ry Other p Number of living units: ________ Number of bedrooms __Z__ Number baths J--- Lot size . DD___-x__ i ------__------------- d Water Supply: Public system ❑ Community system C] Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand F] Gravel ❑ Sandy Loam E] Clay Loam ElClay E] Adobe Hardpan ❑ " Previous Application Made: Yes ❑ No ❑ New Construction: Yes 9No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet. I Septic ank: Distance from nearest well___�-Q_____Distance from foundation--- _______--------Material____-- ------------------------ No, of compartments----------- --_-- Size ....-------------------------Liquid de th--------------------------Capacity------ _,0_o Disposal Field: Distance from nearest,welL�_ t&OLCADepth �D --_.Distance from foundation__, f______-.Distance to nearest to } ne__ ____._--_ Number of lines____________ ______--_- _-Len th of each line______�__19�_ _______.Width of trench____ _`P`i__ g �7 Type of filter materi of filter material - Seepage Pit: Distance to nearest weEi----------------------Distance from foundation---------------.___.Distance to nearest lot line______________.__ ❑ Number of pits----------------------Lining material------------------------Size: Diameter------------------------Dept h--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______-____________________.___-_____. ❑ Size. Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from .nearest well--------------------------------------------------Distance from nearest building------------------------------------------ F-1 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 andsregulations of the San Joaquin Local Health District.' iiv (Signedf� ,�i !- ------ --------------(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 ____ ---------------------------------------------------------------------- ---- ----------- --------- REVIEWEDBY----------------------------- -------- - - - -- - -------------------------------------------------------- DATE - --- i -----------------••-----------. BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------'- �'- r-------------------------- Alterations and/or recommendations---------- ------------------- '-----------------------'---------------------------------•---------------------------------- - ----------------------------------------- ---------- ----------- ------------------------------------------ ,mar - -- ---- ------ ---------------------- - - - - --- ------ --- ---- ------------------------------------- ----------- . ---- ---------------- --------- ---- � -------- `e'r- `------------- --- FINAL INSPECTION BY:--------- -— Date--------------1.1....... --- �j----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 8.51 Revised W-2100