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r V � } APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �"1 Date Issued ______ Applica}ion 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. D JOB ADDRESS AND LOCATION--------- �--------- -_ d---------- Owner's Name--------------- -0------------- ----•------------------------------------ ------ Phone.-------------------•- W.Address--------- .. �--•--.....-•--•• Contractor's Name-----��': = - ----------- - - ------'s�---��,t1��. •----- ------------------- •---••-_- Phone-,�--- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/-___ Number of bedrooms _-"577 Number of baths ___-L. 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 [S Previous Application Made: Yes ❑ No Imo. New Construction: Yes [❑ No ZK_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T n Distance from nearest well_________________Distance from foundation--------------------Material_-___-._____.__________________________.._______- ❑ o. of compartments--------------------------Size----....---------------------_Liquid depth--------- ---- - --------Capacity...------------------- Disposal Field- Distance Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line---------------_ ❑ 4 i� umber of lines-----------------------------------Length of each line--------------------_--------.Width of french----------------------------------- Type of filter material-------------------------Depth of filter material----------------------- otal length____________-_-___________-_______________ N Seepage Pit- Distance to nearest well ___Distance from foun�lation__e _!------Distani? to nearest lot line_---�_ W Number of its__ -- ______________-Linin materiaLC --_ >�: Diameter___ 7 --- P 9 � - ."..�----------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---------------------------- ---------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--------- -----------------------------------------------------------• ----•-----------------•-------••-- --•---•---•-------------------•---------------------------------------------•--------------------------•------•------------------------ --------------------------------- G -----------------------------------------------------------------•-----------------•-----------------------------------------------------•--.....-----•.----- ------- ----------- A ------------------------------------ ------------------------------------- -- ---------------------------------------------------------•---------------....--------------------------------------------•-----------------------------------•----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances. State I , an rules and regulations of the San Joaquin Local Health District. (Signed) ------------- ----------------------------- and/or Contractor) �y= �� ----------------------- [T eJ itl (Plot plan, s owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------- ------_-------------- DA ------ ---------- --------------------------------- REVIEWEDBY--------------------------------- - ------ -- --- ------- --- ---------------------------------- DATE --- BUILDING PERMIT ISSUED------------ ------ ------ ------------ ---------- ---------------------------------- DATE ----- ' Alterations and/or recommendations:------------------- - . --------------------------•--------•-••------------------------------------- ------------S- ---•---•------------------------------------------•------------------- - - -------------- ---------------------------------------------------------•---•------•----•-_-------- ........... . ----------•----•- ---•------------------------------------------------------...------------------------------------------------------------------------------------------------ FINALINSPECTION BY:.-------------------------------------------------------------------------------------------------- Date.-------------.-----------------s-------------- --•--------------------------• 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 E5-9-2M � Revised W-2100