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APPLICATION FOR+SANITATiON PERMIT Permit No. _4_----.-- (Complete in Duplicate) , Date Issued Application is h reby 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 Count , Ordinance No. 549. JOB ADDRESS A '' LOCATION_--- -- Owner's Name = ----------- Phone_�_� -4/--1 -------------------------------- Address------. ' Contractor's Name--- -•-------• -------------------- ------ Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _______ Number of bedrooms ________ Number of baths -------- Lot size ----------•------------------------ Water Supply: Public system ❑ Communify'sysfem°El- Private-❑-..Depth-to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loa rn ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes [] No ❑ TYPE OF INSTALLATION AND.SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from neared well-----------------Distance from foundation--------------1-----Material______________ El ----------------------- No. of compartments--------------------------Size-- _--------------------------Liquid depth--------------------- .--Capacity----------------------- Disposal Field: Distance from nearest well------------------Distance from foundation--,------------ to nearest lot line___-________..___ 'y ❑ Number of lines-----------------------------------Length of each line------------------------1----Width of trench------------------ Type of filter material--------_----------------Depth of filter material------------------I----Total length--------------------._____ ---•------------ Seepage Pit: Distance to nearest;well----------------------Distance from foundation--------.----."___.Distance to nearest lot line_.____.- ___.._ ❑ Number of p:ts-------- -------------Lining material-----------------------Size- Diameter,---------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundat:on______________'---.Lining material_______ __ ❑ Size: Diameter. Dept Liquid Capacity--t~ = --- -------- a s. --------- -- - - --- 1 , Privy:,. Distance from nearest well.___.__ - _ _______ ____-----_____Distance from nearest buildin r 9 Distance to nearest lot-line -. - --•-. -- Remode' g and/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 r.� ) Sy:----------------------_-----------------------• ---------------------------------------------------------------------------- -----(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 APPLICATI,ON`ACCEPTED'BYQ______ ____________________.-____- DATE ----------------------------- e ------------ --------------------- REVIEWED BY ----------- --------- DATE--.---,g? . -------------- BUILDING PERMIT ISi LED---------- --- DATE--------- - - ----------------------------------------------------------------------------- ----------------------------------------------------------------------------------- ---------------------------------------------- Alterations and/or recommendations:-------------------------------------------------- �______ ----------------------- --._________________-___._.___ .__ _______.________________«_________-_._ __________________________________________________________________ .. __--__-- _._._________________ __.______._..�_.1___-_____--_________--_________-___________________.______----____--._._.____ ----- -- _ I xv- Y . ------------------------------------------------------------ --- f - -- ----- = , � ----------- r --------------------------------------------------- .------- FINAL INSPECTION BY: -V,------ Date . _ _ -------------------------- .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 ES-9-2M 10-52 Revised W-2100