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APPLICATION FOR SANITATION PERMIT Permit No. 411-5� (Complete in Duplicate) Date Issued -_�-".�--�-�`� Applica*ion 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. - 0 �.. JJOB ADDRESS AND LOCATION------------------- ---------------------------------------------------------------------------- Owner's Name------------------------- 1 ----------- !9 '-� ---------------------;----------------------------------- Phone------------------------------ _ Address___ ---------•----------------------------------------•--•-----••--•----------------------------- ---------------- Contractor's Name-------------------- 11'---------}---------------------- --------------------- ------ --- 1 ---- Phone------------ -•-•------•------- i Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑, Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size -_----__--------------------------------------------------- Water Supply: 'Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft., Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ IPO Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ y TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No septic tank or cesspool permitted if public sewer is,.ayailable"within 200 feet,) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------.Material'------------------------------------ --_-_. ❑ No}of compartments--------------------------Size---------------------------- =Liquid ,depth--------------------------Capacity----------- ----- Disposal Field: Distance from nearest well.................Distance from foundation-------- .----.Distance to nearest lot line----------------- F-1 Number of lines-----------------------------------Length of each line-----------------------------.Width of french-----------------.----------------- Type of filter material------ ---Depth of filter material-------------------------------- length------------------------------------------ Seepage Pit: "Distance to nearest well------- from foundation--------------------Distance to nearest lot line-__----___------ , ❑ Nu.mber of pits-------- --------------Lining material-----------------------Size: Diameter----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation_.___:___-.--- _ Lining material------------------- ---------------- ❑ Size: Diameter-- -----------------------------------De th ---------------------------------------------------Liquid Capacity-.--------------------------gals. �r Priv Distance from nearest well----------- -----------------Disfance from nearest buiidin �D----------- __ __-_-_-_ ( Distance to nearest lot line- -----------------LQ.............................................. V) 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 rules and regulations of the San Joaquin Local Health District. ei r (Signed)----.V -- --- 4 1 =---- ---------------(Owner and/or Contractor) (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 APPLICATIONACCEPTED i3Y----------------------------------------- _ - --------------------------------------------------------------------------------- DATE-------------__-- REVIEWED ' BY------------------------------------ ----- ------- -------------- --------------------------------------._ DATE---------------- ---------------------------- ------------- BUILDINGPERMIT ISSUED---------------------------------------------- ------------------- -------------------- ------- ----- DATE------------------------------------ ------------------------ Alterations and/or recommendations:-----------------------------------------------------------------------------------------------------•------•------------------------------------------------- ----------------------------------------------------•-------------------------------------------------------------------------------------•--------------------------------------------•-•----------------•...--••-•--------- -----•--------------- ------------------------------------------•-----------------------------------•----------•-------------------------------------------------------•--•--------------•--------•--------------:--------- ------------------------------------- ------------•------- -------- ' -- -----------•---------------------------------------------------------- ----- ---------------------------------------- 1 a FINAL INSPECTION BY::: Date 1::.. - 7 ------ ----- ---------------- -------------------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore S#reef 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised.W-2100