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F APPLICATION FOR SANITATION PERMIT Permit No. V4---------p--•-- _... (Complete in Duplicate) Date Issued &Z-0 --�� 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. 549. JOB ADDRESS AND LOCATION----------- -------- ------------------------- ------- ------------------------- -- ---- Owner's Name------------ '--------------- -------------- - --•-------------------------------------------------------------------------- Phone------------------------------------ Address------------- -- _-------- -- ------------- -----------------------------------------------•-------...: Contractor's Name------------ ---------------- Phone__. Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court [] Motel El Other ❑ Number of living units: J---- Number of bedrooms __ ---_ Number of baths I---- Lot size __` / 3;---------------- ----------- Water Supply: Public system ❑ Community system ❑ Private 9'6epth to Water Table Ve- ft. depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Character of sod to a p ❑ Previous Application Made: Yes ❑ No �Iew Construction: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ----- Septi .ank: Distance from nearest well _ +Distance from foundation__�_6-_•-.____-_Materijl____ ^ 'i^�'- - No. of compartments r Size_ --9-�- f iquid depth f?�-----Capacity---�----------- Disposal Field: Distance from nearest welL�±b_Distance from foundatioq_�_�__.____---Distance to nearest lot line��-�_.___ e^ Number of lines--------t------------------------Length of each line--------(�---u--------------Width of trench------fir- -- ---------------- Type of filter material----------------______---Depth of filter material-----------------------Total length------------------------------------------� Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material----------------------Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-____________-_.----_-_-_______-_.__. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance frorn nearest building------------------------------------------ Distance __________- ___________------------.Distance 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 rul s and regulations of the San Joaquin Local Health District. (Signed)..--- -9'-1------- ------------------------------------------------------------- -�---------------------------(Owner and/or Contractor) 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---- ------------------------------------ -------------- REVIEWI=D BY------------------------------------- - ---------------------------------------- DATE-/ : ' --=- ------—-•------------ ' - - ------------------- DATE--- ---------------- - BUILDING PERMIT ISSUED------- -------- ---------------- ------------------------------•-------- --- -----------------------:_f__.�------- Alterations and/or recommendations-------------------------------------- --------------------------------------------- -----------•-•---------------------• -------------------------------------- -------------------------------------- ------- --------------------------------------------------- -------------------------------------------------- FINAL INSPECTION BY:--.W_.V_/�--------------- -------------------- Date-----> '----- -.4 2`- ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S}reet 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