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?� APPLICATION FOR' SANITATION PERMIT Permit .,. (Complete in Duplicate) Date Issued -- { Applic tion 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, / l JOB ADDRESS AND LOCATION---- --- --- ----- �,. ------ ^,�'" 1------------------------------••-----------------------------------------------..._- Owner's Name � � $----------------------------- --------- Phone--------------------------------------------------------- --------------- -- ----------------------------- ---- , __. ------ ' rQ ---------------------------------•----•------f---------- - Address----------•----------------------------------------- l/ ..._ r' Contractor's Name------------------------------------------------------------------------------- --------------------------------------•----------------------- Phone...... _...------•-------------•-- Installation will serve: Residence f4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑/ Number of living units: .___ Number of bedrooms _/__ Number of baths Lot size Water Supply: Public system K] Community system ❑ PrivateW. Depth to Water Table -------- ft. r Character of soil to a depth of-3 fee+:.Sand ❑ ,Gravel ❑ Sandy Loam ❑ Clay Loam ❑ - Clay ❑ Adobe © Hardpan ❑ Previous Application Made: Yes ❑ No ® .,New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: S�l (No septic tank or cesspool permittedIif public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well--- Distance from ounc�t�on__.'�_ ___._.Mater al-_--r�-C _-_-I< ______________ No. of compartments ____..Ca Capacity �'o____ ®. . p �-----------�---Size---�.1�-- --�--�---Liquid depth---------��--- p Y---•�---- - Disposal Field: Distance from nearest well____�(�-----Distance from foundation-----.'. _-__.Distance to nearest lot line-----,'>--------- 5Q Number of lines__________ 7_'d_ _________Length of each line-------(� ._� Width of trench_ _-_ - -----'-=--------- Type of filter material-S$- __-Depth of filter material_-__ �_._Totals+alength-._-... _______________________ Seepage Pit: Distance to nearest well-----------------_----Distance from foundation_...•______-____-...DistanceJo nearest lot iine----------------- ❑ Number of pits----------------------Lining material-----------`-----------Size: Diameter--------'------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------- Lining*material_-_---______------ ----__------ ❑ Size; Diameter.-------------------------------------Depth------------------------------ ----------.LiquidlCapacitY----------------------------gals. I Privy: Distance from nearest well-------------------------------------------------Distance from nearest buLilding------------------_--_-------- ------ - --. ❑ Distance to nearest lot line----------------------- - ------------ -------- ------- --- -- ----------------------------------------- Remodeling and/or repairing (describe) ------------- - ' • --- --•--- ------------------------------- ---------t--------------------------------------- J �-�'-�=--4--."' t. :• ----------------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 law and rules and regulations of the San Joaquin Local+He'alth District. . ��(Signed)- , ._ ...v - ----------------- Owner and/or Contractor) 8y:------------------------------------------- --•-•------------------------------------ ---------------------------------------(Title)---------------------------•---------------- ---------------- (PI ot -- --(Plot plan, showing size of lot, location of system inrelation to wells;buildings, a+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --------- DATE------ ----------------- REVIEWEDBY------------ -------------------------------------------------------------------•-----------• DATE---------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------- ------••------ ------------- -------------------- Alterationsand/or recommendations:---------------- ---------------------------------------•---------------------------------•----------••-----------------•-•-------•------------------------- ---..._.----•--------------------------------- ------------------------•------------------------------------ --------------------------------•--------•----------------------------------------------------------------------- -------------------------------------------------------•------------- ----.-------------------------.--.-----.-------------------------------•-------------------------------------------------------•--•---------------- FINAL INSPECTION BY------- ------- '' - Date..-.--------- -f - - --- - ---- ----------------------------- 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