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APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate) Z Dafe i 44 ssued .___�__��__/-�`i—' Application 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. 5.49. -.JOB ADDRESS AND LOCATION_____ -__---- ------:!A____ ______________ Owner's Name--------- ------- -----------------=--- Phone Address-----------•-------•---------i;7?- ------ ---- Contractor's Name .��i±-'�.'~ Phone Installation will serve: Residence Nd Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _- __ Number.of bedrooms____ Number of baths /----- Lot size __ __ _ _ __ __________________________ Wafer Supply: Public system ,Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ElClay Loam ElClay E] Aclobex 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.) 1 Septic Tank: Distance from nearest well____h_4f. -&--Distance frim foundation_1-0-----------Mat�r�al__ =-�__ ______---------- _ No. of compartments__------�-------_-_-Size__�__X----�__�---------Liquid de.pth___3f�:-_______Capacity_ _�__-------- Disposal Field: Distance from nearest well-?F4�-.Distance from foundation_- 4)-----------Distance to nearest lot line_.6_-________ Number of lines--3------------- __ Length of each line_W_`Y47 ?0---Width of trench_-- Type of filter material_____-____Depth of filter material___le_ ----------Total length_-_1 -- ---------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest [of line______________-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation___________________.Lining material---------------------------------------- __Li uid it ❑ Size: Diameter---------------------------------------Depth----------------------------- -- ------------ q Capacity Y--------•-------------------gals. Privy: Distance from nearest well--------------------------------____________-_____Distance from nearest building------------------------------------------ ElDistance to nearest lot line---------------------------------------------------------------------------•------------- ---------------------------------------------------- Remodeling 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 g -----------✓{1� i--------------------- ----- -- -- - -- - - - - ( / r Contractor) OY:---------- -- - _ = - - ---- /nf�o ------------ -----------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of 1 t, ocation o system in relafwells, buildings, etc., can be placed on reverse side). . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED SY----- - --------------------------------------------------------------- DATE REVIEWED BY------------------------------------- DATE- _ ----- ---'=f'~ `i-- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE----- ------------------•-------------------------- Aiterations and/or recommendations:-------------------------- -- ----------- -------------------------------=------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- ----------- ----------------------------------------------------------•----------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ---------------------------------•------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- u FINAL INSPECTION BY: W-- ----- ------ -------------------------- Date------ Q 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 8-51 Revised W-2100