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i APPLICATION FOR SANITATION PERMIT Permit No. ------------------------ (Complete in Duplicate) �-- P Date Issued ---------------�5 Application is hereby made to the San Joaquin Local ealth District for a permit to construct and install the work herein described. This application is made in compliance with Coun rdinance No. 549. JOB ADDRESS LOCATION_-__-- _ Ik---- - -------- --- -------------------------•-- _ ---•--------------------------------------------------------------------------------- Owner's Name---------- - ------ ------ Phone------_��"--------- ------------------------------------------ Address.--! 1.I-- -------------------- Contractor's Name.... --- - ------- ------ Phone----------------------------------- Installation will serve: Residence partment House ❑ commercial ❑ Trailer Court ❑ Motpl ❑ Othej ❑ ' Number of living units: umber of bedrooms 5;;YNumber of baths --Z- Lot size _ [ ___ - - ------------------------- Water Supply: Public system Community system [] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sd Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe �ardpan E]E] an Previous Application Made.- Yes No New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 'f public sewer is available within 200 feet ' Septic nk: Distance from nearest well ___ _ ,#C _ _ ' public ce from fo �ydon---- ------------Materi 1'PJA"u'l-� _.___---_-_-„--LL--- - No, of compartments______-_-__ - J� �X�(!-____Liquid e tk�-__-_ ---_--_-__Capacit67 y -?"� Dispos Field: Distance from nearest ell ___ _ istance from foundation - - istance to nearest lot in t tt Number of lines___________ I Length of each line__._____ __ _ __.Width of trench---__------- _ _r_____________ of filter mater q� ��iDepth of filter material---_-----�-- - ---Total length---_:--_-•-•�- -Q ------- Type Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot 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-----------_-------------------------------------Distance from nearest building_-__------_-_-___- _._._--__.__-_-__---. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------••-------------------- Remodelingand/or repairing (describe):--------------------------------------------------------•----------------------------------------------------------------------------------------.-:.. .. ------------------------ ------------------------•--------------------------------------•---•------------------------•-•-• ------------------------------- -1 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 ----------------------------------------- �1 (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 13Y ------------- DATE ` BUILDING PERMIT ISSUED--------------- -- ---------------------------------------------------------------------------------- DATE------- Alterations and/or recommendations:-- ----------------------------------------------'----------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=----------------------------------------- ------------------------------------------------------------------------------------ --------------- -------- - - -------------------------------..---------------------------------------------------------------- FINAL INSPECTION 13Y: --------------------- Date 2 -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M 8-51 Revised W-2100