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{ APPLICATION FOR SANITATION PERMIT Permit No. 1a --7--__-_ (Complete in Duplicate) Rate Issued 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 rd inane No, 549. JOB ADDRESS Ai1D' LOCATION k . -- - - ----- - -------- ----------------- ---------------------------------------------------------------- Owner's N�re Phone ----------- ------- ------------------------------------------------------------ Address ----------------- -------- --------- Contractor's Name--- ------ --------- -------- ------------------------------------------------------------------------------------------------------------- Phone----------------------------- Installation will serve: Residence t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 a Number of living units: _-�---_ Number of bedrooms J--- Number of baths --1---_ 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 ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ 'No 2 New Construction: Yes VNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic s9wer is available within 200 feet.)/ Septic Tank: Distance from nearest well--- --- __Distance from� foun " tion--_�_-.------.Mater- I ---_ No. of compartments----------- ---sy-__Sizex1(!__ Liquidryg dept_____----_ �-------_Capacity_� __s-_ Dispose Field: Distance from nearest well�-_.=1-_-"Distance from foundation----rS[- Distance to nearest .ine---_ -- Number of lines-- - --_, _ ---__--- ' Length of each line------------ Width of trench-----. i____ ------------- , � - , Type of filter materia_______ __ __ ____ _epth.of filter material--------- ---------Total length---------- -_�_�_--------___---__-. i Seepage Pit: Distance to nearest"well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest welf------------------Distance from foundafiion--------------------Lining material--____-------_-------_-_--______----_ El Size: Diameter----I---------------------- --------De th-------------------- -------_--_Liquid Capacity --gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__-_----_-_-______----____----__----- ❑ Distance to nearest lot kne---------------------------------------------- ------ -------------------------------------------------------------------------- R odeing a� scib . ----- ------ ---- -- , ------- -•-"-�-- --- •-,-------- --- ---- - ---- ---- - - - - ---- - - - - --------- ------------------------------------------------------------ ------------------------------------ ----------------------- - ----- ---------------------------------------------F�------- r i 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 Joaquin Local Health District. {Signe ----- - - - -----------------------------•-------------------------------------------------------(Owner and/or Contractor) M , By-------------------------------------------------- -- ---- ---------------------------------------------------------------------------(Title)--------------------------------------------------------------- 4 (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- ----------------------------------- ---------- REVIEWEDBY------------------------------------------- ---------------- ------------------------------------------------------ _---- ------------------------------------- DATE BUILDING PERMIT ISSUED--------------------------------------------- -- -------------------------------------- DATE -- ------------- Alterations and/or r- o mendations:_, _--------_--_-__-k-------------------------------- _ ------------------ ------ �f--------------------------------------------------------- - �. --f- -----•-- -- -------I----- --- ------------ --------------------------------- ----------- ------------------------------------------------------------------------------------------------- FINAL INSPECTION BY--- -------- ------ ---------- Date/-4�-------V-77---,U-7 I 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 i ES-9-2M 8-51 Revised W-2100