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APPLICATION FOR SANITATION PERMIT Permit No. _.__-- �___.,-� (Complete in Duplicate) _sy Date Issued _____��. _-/__-- Applica11kior�n is hereby made to the San Joaquin Local Health District for a permit to construct and instal[the work herein described. This application is made in compliance witIj Count Ordi e Nrn 49. JOB ADDRESS AN VOCATION____ _ f_.( ' 1 ---------------------•--•---------------------------- -- Owner's Nqqame_...__. ----- • -�---- � -•- -- -- -- -- -----••-•- ---------••----- - � -�- - -------- - ------ ----------------------- -- - ------ Phone- -� 73-0..... Address--h�s ---- - - ---------- ------------------ Contractor's Name----- -------- ---•-------------------• --------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial railer Court ❑ Mot9I ❑ Oth r f❑ Number of living units: -------- Number of bedrooms _____-- Number of baths____ Lot size __ lf__-__X jjT _____________________ Water Supply: Public system [❑ Community system ❑ Private Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand M Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adobe • lardpan E]Previous Application Made: Yes E] No / New Construction: Yes ;No ❑ TYPE OF,INSTALLATION AND SPECIFICATIONS: Co septic tank or cesspool permitted if ukoic��s4wer is available within 200 fe//e��t,,.,,Y Septic ank: Distance from nearest well—0�'!_.anc fr f&Q4fion_/Vt ' - ++�� - ------ Mat•e�ji No. of compartments___-____-X�--#-----,_Size _ �x6__----Liquid,dep#h___ -----'T__------_-__Capacity___ �.___ Dispos Field: Distance from nearest we ~ -Distance from foundation�0------ istance to nearest lot •n ___dr_______--_- n9 ,/ Number of lines- Length of each line___________ - �/ r Width of trench._ ,rS/.�'� _ ______________ _____ _ � Type or filter mater p g r e th of filter material length Seepage Pit: Distance to nearest wel#----------------------Distance from foundation------------.------Distance to nearest lot line__.__.____.__..__ ❑ Number of pits-------------4 ------Lining material-----------------------Size: Diameter----------------- - ---Depth------------._.------------ ----- Cesspool, Distance from nearest weil-----------------Distance from foundation___________________Lining material__.__________________--_____.______ ❑ Size: Diameter--------------------------- ----------Depth------------------------------ ---- ----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------_----------_--------__---------------------Distance from nearest building___--____-.__.______________._...___.._ ❑ Distance to nearest lot line-------- -------------------------------------•---------------------------- Remod ing and/or repair' es be ._.------------------------- ----- - _ - --------- -- ----- -------- - - ---- -- - -------------------------------------------- ----------------------------------------------------------------•---------------------------.---•-----------•---•------------------•------------------------------------- ---------------------------------------------- ------------------------•------------------------------------•-•--------------------------------------------------------------------------------------------------- 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 Contractor) 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 ---------------------------------- ---- --------------------- -------------------- ---------------------- ------ ----- - REVIEWED BY ---PER DATE-------- Alterations and/or recommendations:_----------- ----------- - `-------------------------------- ----r----------;---------------- --•-•--- -----------------•--------------------- -•--------------- ---------------------------------•-----•---------/------ ' --------------------- ------------------------------------------------------------------------------------ -------------------------------------------------------------------- --_- 4.1; ------.------------ ------------------------------------------------------------------- -------- �- .-----------------------� --------------------•� hrMme ------------------------------------- ------------------------- � �j- - FINAL INSPECTION BY-------- ------- 7�- __--- - ------------- Date-- .-. --------/a------------ SAN - -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-32 Revised W-2100