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APPLICATION FOR SANITATION PERMIT Permit No. ------ (Complete in Duplicate} Date lssued�+ �4 gplica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thiapplication is made in compliance with County Ordinance No. 549. JOB ADDRESS AN LOCATION...,�_r_ 0 ---- ------------- T Owner's Name----- -----'---------- '�------------(-- ------------ ---------------------- Phone7 JJA Address------. .. - Contractor's Name !✓. ' - --------------------------------•-------- Phon -Glf2 Installation will serve: Residence PI--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/--- Number of bedrooms -,L... Number of baths .1--_ Lot size ----------------------------- Water Supply: Public;system ❑ Community system 2;15`rivate ❑ 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 [ New Construction: Yes ❑ No Lg' TYPE OF INSTALLATION AND SPECIFICATIONS: (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 dep'k---------------- ---------Capacity----------------------- Disposal Nielld5 Distance from nearest well_ ---_ /--Distance from foundation-----_ ..._.Distance to nearest lot line__�4------ d r Width of trench - a �e- Number of lines_. ___,_._._ ��_ __ ..__-�__Length of each line________ _.__ Type of filter material� ___ __Depth of filter material______ ._` ----Total length--;_ 3-Q__.----:---------------- ---------------- Seepage Pit: Distance to nearest well_._. Gd-__------Distance frofou dation___.__o--�__,....Distance to nearest lot lin -------- S_-- Number of pits---------l--_._.__-_Lining material- ----r *�r .Size: Diameter----J�..-_ Depth - _ �1 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-"_____--_-__________.____-_____-___. G ❑ Size: Diameter- --------------------------------------Depf h----------:--------------------------------- Liquid Capacity-- -------------------------gals. Privy: DJ stance from nearest well-----------------------------------.----------.."Distance from nearest building----------------._- ❑ 3 Distance to nearest lot line------------------------- -- ----- --------•--------------•-----------..------------------------------------------------------------ -- Remodeling and/or repairing (describe)--------------- ---- -- 4� -------------------------------------------------------------•------------------------------ ----------••---------------------------------------------•------------------------------------------------------------- ••---------------------------•-------•-•----------------------------------------------------------•----------------------------------------------------------------------------------------------------------- -------------------•-------------------•-------------•-----------------------------------------------------------•---------------------- -------•---------------•--------------------------:-------------------------- I hereby certify that l have prepared this application and that the work will be' done i,h accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health Disfricf. ` ;+�+�•- _-_-_.--__-_-___ _ and/or Contractor (Signed{------------ -�� -{--- ---- --------- ----------- ----------- ------------------------------------------ --� --- - ----- --- / ) ------------- By:............d - - ------------ .. ----------- --------------------------------------••----------------------{Ti+le} ----------- (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 APPLICATION ACCEPTED BY--------------------------- -- -------------------- - - --------------------------------- DATE---------- = REVIEWED BY--------------------------------------------- -------------------------------------------------------------------------=----- DATE-------------------- ----------- --------i--------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------- --------------------------- ---------------------------------------------------------------------- --------•--------------------------- ry _-f- ----------_----------� --------------------------•------------------- -----•--------------••------------------------------------------- ----------------•-•---•--------- -------------... ............---------------------- e ° " -------------------------------- ------------- ----•- ------------------------------------------------------ -------•--------- ------------------------- •------------------------------------------,-----------------------------------: ---------- ------ ----------- ------ --------------------------- I FINAL INSPECTION BY: °" -�� Date------ ----'- / �� 1 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 ; Revised W-2100