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APPLICATION FOR SANITATION PERMIT Permit NN .. - "� (Complete in Duplicate) 7 Date Issued __: Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work her in described. This application is made in compliance with County Ordinanc No. 549. JOBADDRESS AND LO TION ----- ) ------ --- -----t --- -----------------------------------------------•---------------------------------- ----------------- Phone---- '"---- Owner's Name----------------- ------ '" . -------------1... -3--° -----�' - - -- . ----- -- - - -------------- --------------------------------------------- -----------------------------------------------------------. Address...._ Contractor's Name------------------•------------------,----------------------------------------------------------------------------------------------------. Phone----------------------------------- 3. Installation will serve: Residence'? Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel I ❑ Other ❑ � Number of living units: ----i--- Number of bedrooms --I---- Number of baths !------ Lot.size ------5.0-_---_- __t-- `Q______________________ Water Supply: Public system ❑ Community system '❑ Private W 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 X New Construction: Yes ❑ No 5d TYPE OF INSTALLATION AND SPECIFICATIONS: ; [No septic tank or cesspool permitted if public sewer is available within 200 feet.) ee,�� Septic Tank: Distance from nearest well-----3__V___D.istanceVfrom foundation------7...........Material-.--___(f604t1______________ No. of compartments------- --------------size__ XIk----4'------Liquid depth------�!r--------------Capacity--I?.' Disposal Field: Distance from nearest Distance from foundation______lei------- Distance to nearest lot line----nr____.__ 19 Number of lines,--------- --- -----------------------Length of each line---------k-a-----------Width of french------ -----._---------- Type of filter material_-) Depth of filter material-------!,0.'---------- otal length-------------- ____---_----- Seepage Pit: Distance to .nearest well------------------._ Distance from foundation-------------------.Distance to nearest lot line__---`____-----_ ❑ Biu, Number of pits----------------------Lining material---;------------------.Size: Diameter----------------------_Depth--------------------------------- ' S Cesspool: Distance from nearest well_________________Distance from foundation--..--------------- Lining material------------------------------------- ElDiameter--------------------------------------Depth-•-------:------------------------ -----------------Liquid Capacity----------------•--- --gals. Privy: Distance from nearest well--:-----------------_-_-_.--:-------------------Distance from nearest building----------.-_-_-________________.________. ❑ Distance to nearest lot line------------- -------------------------------------•--------------•------------------------------------------ ------------------------------- Remodeling and/or repairing (describe) 1) ��-------••------------•--------------------- ------------••-•-------.------------------------ --------------_---------------------- -----•-----------•--------------------•------.----------•-•-------- .-...--------•-------------.. ------------------------..---------------------------------------•------------- ---•-•--•-•------------•-----------------------•---- ------------------------------------•--------••------------••------------------------------------------------ •------------------- •-----------•---•-----------------------•---•-----------------------------------------------------------------•---------------------•--------------------------------------------------------------•------------------- 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. r (Signed)--*14 ' �`' *'� ` �^�•`' Owner and/or Contractor By:--------------•----------------------- -------------------- ------•--------------------------------------;--------------------(Title)------------------------------------------------------------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). �. /� t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- / % # ----------- --------------------------- DATE 7___ REVIEWED BY ---- --------------- DATE ----- --- BUILDINGPERMIT ISSUED---------------------------------------------------------------- {------------------- DATE----------------------------- �..t Alterationsand/or recommendations:---------------------------------------------==---------------------------------------------------------------------------•---------------------------------- -------------------------- ---- -------------------------- ----------------------------------I---------------------- ---------------------------------- •--------------------- -----------.- -----•-----•------------------------------- -------------•------------------- --- ------------------------------------------•-------------------------------------------------- ----------- I-------------------------------------------------------------------------------------- ------------------------------- --- ---------------------------------------------------------------- FINAL INSPECTION BY:-------- -� - - --------------------------- Date. r ' �� ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes# Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M a-51 Revised W-2100