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APPLICATION FOR SANITATION PERMIT Permit No. _. .Z- -.--- 3 (Complete in Duplicate) 1 Date Issued.---•-!��---- Applica n 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 hhyCounty Ordinance No. 549. JOB ADDRESS AND LOC ION--------------�/ _-�-- S-:----- -------------- ---------------------------------- -------------------------------- Owners Name - -------------------- -------•--- Phone----------------------------------- L , Address------------------------------------------------------------------------------•------------------------------------------------------------------- Contractor's Name------`------ --------------------------------------------- -------------------------------------------- Phone----------------------------------- Installation will serve: Residence artment House ❑ Commercial (] Trailer Court ❑ Motel ❑ llOther ❑ i Number of living units: 1---'Number of bedrooms _-Number of baths -=-�_- Lot size -------- - -- --1- -Q----------------------- o rw Water Supply: Public system P/C'tommunity system ❑ Private ❑ Depth to Water Table ----.--. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [,d1 -Hardpan ❑ Previous Application Made: Yes ❑ No F"New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I ! (Nonseptic tank or cesspool permifted if pu is sewer is available within 200 feet.) ', . Septic Tank: Distance from nearest well_- - wistance from foundation--_/vp .�vlaterial- No. of compartments--.-_-. Size _..Liquidh---------f+__.. :Capacity ., Disposal Field: Distance from neares well"-!rA'?-1&Distance from founda ion___I_ "-" -- istance to nearest lot line-_--- ,� --�. Number of lines..--. ------------------.__Length of each line_-��_--_�''��Width of trench---. ..-----_ _----------.---.---_ Type.of,filter material517, __-Depth of filter material------L-T-----.-_--Total length----------- -- ------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------_.----__ ❑j Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well--------.--------Distance from foundation______________ ____Lining material_-_-----------------.- I ❑ Size:-Diameter-------------------------- ---------Depth----------------------------------------------------Liquid Capacity-------------------------..gals. Privy: # Distance from nearest well--------------------------------------------------Distance from nearest building--- ..---"__"___-____.--_____.__ F17- _ "Distance to nearest lot lire--------------------------------------------------------------------------------------------------------------------------------------- I Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------------------•------------•-- $" ------------ -------- ------- ------------------------------------- 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 laws, and ruin apd regulations of the San Joaquin Local Health District. 4- - (Signed --- -----�..467Y- -- ------- -----------------------------=--------------------------------------------------------------(Owner -------------------------------------- ---------------------(Owner acid/or Contractor) 11 By: (Title)_ -------------------------------------- (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------------- -'-----------------i--------- REVIEVVEDBY =°.`------------------------- ------------------------------------------ -------: --------------- DATE----------------------------------------------F------------- BUILDING PERMIT 1SSlIED.. -----------------------s --------- DATE = - io---------- and/or recommeridations----------------------- -------- ------ - ---- --------------------------•-------•---•--•-------------•-•-=----------•---•------------------ ---.:----------------- - ---- f - - i z -----•----•----------------------------- --- -•---------------------------------------------------------------------------------------------------------- --------------------------------- -------------------------- ---------------------------------- --------------------.---.---------- ------------•-----•--- -- ----- ------------------- --------- ---------•------------------ -------------------- -------------------------•--------------------------------------- FINAL`INSPECTION BY-------------------- ------ - -1 - - Ze ....... Date-----------------�-/�- -------L- 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 i IRevised W-2k00