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APPLICATION FOR SANITATION PERMIT Permit No, __----.lZ� � (Complete in Duplicate) n ! A'/ZI—Lr3 ,� / Date Issued __ ______________ Applicatio5ereby ade 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), TI N_____ ___r_ D- _i� �. (�[;, ----------- ------ ------------------- Owner's Name ----------------------------- Phone Address-------- ... ,r - . ---- Contractor's Name •- - -----•-------•-------------------- Phone--- Installation will serve: Residence Apart of House ❑ Commercial ❑ Trailer Court ❑ otel Other ❑ Number of living units: .-/ Number of bedrooms _-__ _ Number of baths : Lot size ___ __ _r7Q.-d Water Supply: Public system p Community system ❑ Private Depth to Water Table _ t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or.cesspool permitted if public sewer is available within 200 feet.) IF Septic Tank: Distance from nearest well_____ _. Distance f m undat' Materi �'-- --------'-- iso. of compartments-------- ----------------Size----.-7`, _ Liquid depth--------- --------------Capacity-----R-4p-cl--= Disposal Field: Distance from nearest well ...Distance from foundation------A3--'V-..-.Distance_ _ to nearest fofi line`--�____.__ rn Number of lines---------1_____._ �ength of each line---------6-- --___ Width of trench._-- [• Type of filter material__,-� __. - epfh of filter maferial------ ' Total length____-___ "' _ - ------------------- Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distance to nearest lot fine__________.___ ❑ Number of pits----------------------Lining material----------------------Size: Diameter------------- ---------Depth---------- -------------------; Cesspool: Distance from nearest well_______________ Distance from foundation--------------------Lining material--------------------._- ❑ Size: Diameter--------------------------------------Depth----------------------------------- - -- Liquid Capacity--- --------------- ----- nvy: Distance from nearest well---------------------------------------------_-Distance from nearest buildingi � 1 ❑ Distance to nearest lot line------------- ---------------- ----------------------------------------- .r�. Remodeling and/or repairing (describe):.......... -------- _ ---------------------------------• ----------------------------------------- --------------------------------------------------- ------•----------------------------------------------------•--------------• --•------------•-----------------•--------------•--------------- •---------------- ------------------------------------------•------------ -- -------------—--------------------------------------------------------------------------------------------------•----------------•-------------- --------------------------------------------------------------------- ------------------------------------------------------------------------------------------- ---------------••----------------•------------------------------------------------------------------------------ I hereby rtify that I have pr pared this application and that the work will be done in accordance with San Joaquin County ordinances, S to la , and uld regulations of the San Joaquin Local Health District. (Signed).. ---- - - - ------------------------------------------------------------------------------------------(Owner and/or Contrac 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-----------• - ----- --------------------------------------- ED BY--------------------------- ------------ ................... --- --- ---- DATE---- f ,.• �{+'�� BUILDING PERMIT ISSUED DATE-------- /--- . Alterations and/or recommendations-__--_-__ ----------------------------------------------------------- " of - x '� 1 _�- --------------------------------------------------•- ----- ;---•-----------••------------- ------------------------------------------------------•-------------------•----------------•-----------------------..------ �.. —- -- ------ ----------------------- ------- -------------------- --- --------------------------- FINAL INSPECTION BY---------------------- Date------- --- f _ - - 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 10-52 Revised W-2100