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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued __Y/'_p 6Y Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 3 This application is made in compliance with County Ordinance No. S49. JOB ADDRESS AND LOCATION_____________/ _5�____ ," M.- -- v Y - Owners Name___________ _-___ 1/1 __-- ---�-�---�_.------- - - -------- e"'-------------------------- -'--------------------------------- Phone----�-��-�------------- -- Address------------ �� f --- -- --------—---- n 6 ----------------------------------•-------- Contractor's Name------ -------!------------------------------------------------------------------------------------------------------- Phone------------------------------ Installation will serve: Residence 2 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.t—' - Number of bedrooms y Number of baths _ `Lot size ____ --------------- Water --.---_- -._-Water Supply. Public system ❑ Community system ❑ Private �epth to Water Table --�--�- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay [❑ Adobe ❑ Hardpan ❑'1_11N Previous Application Made: Yes ❑ No [ New Construction: Yes ❑ No [E TYPE r011INSTALLATION AND,SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � �`` Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material________________________________,_-___________- ❑ No. of compartments-------------------------:Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number oflines.-------.--------------------------Length of each line------------- ___-_-_-_-_.Width of french--------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance. to nearest well—-------------------Distance from foundation--------------------Distance to nearest lot-line______________._. ❑ Number of pits------------------ ---Lining material-----------------------Size: Diameter-----------------------Depth ___-a Cesspool: Distance from ne rest w IL__ --Distance from foundation___ ___.Lining material.______P ._..__. " Size: Diameter__ /Y_-_ Depth _.____�__ ___� _ --- ________Liquid Capacity __ _ _______gals. . ---gym - . �-�, -�--,, - _ -. Privy: Distance from nearest wel------------------------------------------ Distance from nearest building--------------- --------------------------- El ______•___________.__. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------ Remodelin and/or repairing (describe):---------------------------------------------------------------------------------------- ----------------------------------------------------- •-------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- --------------------- -------------------------- --------------------•-•--------------------------------------------------------------------------- - --- --- ---- - 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. ,,.(Signed) - -------------------------------- -------------------------------------------------------------------------(Owner and/or Contractor) By• / `stp-r -- - " -JTEtIE)-------------------------------------------------------------- I (Plot plan, s owing 6i of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY-------------- -------- ------------------------------------------------------------------------ DATE------- t ---------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------•----------=----------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------- Alterations and/or recommendations:---•------------------------------------------------------------------------------------------------------------------------------------------------------- -E------_--_-.---.---____.__________ --________.__________ ____ __,__________R_ ----------------------------------------------------- ---------------------- _____----.___---_.___________ I ---------�- --� S.. .;r k--� - / S. C � ---" ---------a J-�--------�� "` " L-r---=,-------11---�------ y----------------- -` � r' f , Q ----- ---------------- 5 -' j f��' f h --- ---__z�:�s t' --------- FINAL INSPECTION BY: ^ Date � ---------- --------------------------------------- SAN --5 � _-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak.Streaf, 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2106