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r , Permit No. APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date issued - -------------------- f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T1i1S application is made in compliance with County Ordinance No. 549. EC-F-') e j g-r- ' � F �..1 )9' S �� / _ •- ---- - � --------------------- --------------------------------- JOB ADDRESS AND LOCATION Phone Owner's Name------ PS ------------ -------------- - ------------ ------ ----------- -- --- ,-- - - - •---------- Address- -------------- - ---� - - ----- ------------•--__ "--- Contractor's Name-------------- ----•---- Phone------------------- ------------- --•--------- Installation will serve: Residence X61Aparfirrierif House ❑ /Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-.I--- Number of bedrooms ____(-_ Number of baths ----/- Lot size ---------- -- Water Supply: Public system ❑ Community system ❑ Private P Depth to Water Table .g f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pub'c sewer is available within 200 fee/It.) 4-Distance from foundtion------/-Q------.Materi l_------ Septic Tank: Distance from nearest well_-- y p No. of compartments---------�---------Size,- ,r -f-X--- -----Liquid depth ; p y -G3 _ ) Ca acct Disposal Field: Distance from nearest well.....�00-.Distance from foundationj--__�_�_ -------.Distance to nearest lot li�� Number of lines---------,C_-__----- __ Length of each line--___lfJ-_Q- g_.Width of trench.-- - --------------- i Type of filter material__- LDepth of filter material-.-.--_-----9--- Total length---------�QQ------------------ � I Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------.----------Depth-..---------------------____-, Cesspool: Distance from nearest well---------_------Distance from foundation--------------------Lining material--.--_---------------__---.--.-.- ❑ Size: Diameter-------------------------- -----------Depth--------------------- --------------- ------------Liquid Capacity -- a„ '7 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--___-..-----.----------_------.-___------ 1 ❑ Distance to nearest lot Iine---------------------- ----------------------- --•-------------------------------- ------------------ ----------------------------------------------------------.------------ Remodelingand/or repairing describe :-P:k'147 J ,/'t '� "' "" ' `r' --------------'------------------------- d----------- -------------------------------------------------- --- --------------------� ------------------------------------------------------------------------------------------------------------------------------ --------- ---------------------------- ---------------------------------------------------------- ----------------------------- ------------------------------------------------------------------------- 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 5an Joaquin Local Health District. ,X00, j - y /V (Signed)-- 3=#` -----------------------------------------------------------------------------(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 �-- APPLICATIONACCEPTED BY---------- -- ------ ------ ------------•--•------------------------ DATE------------------------------------------------------------ REVIEWED BY------ DATE-------------------�- ------ �- DATE. BUILDING PERMIT ISSUED-------------------- Alterationsand/or recommendations------------------ ------------------------------------------------------------ -------------------------------------------------------------------------- •-------------------------------------------------------------------------------------•-----------•---------- ---------------------------- ---------------------------------------- -------------- ------------•------------------------- ----------------- -----------------------•--------------------------------- -•-------•------------ - + -------------------- Date-----. ".�-�-Q--- ZNorth -------------------- FINAL INSPECTION BY-------------- -- --- --- -- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 811Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M �0-52 Revised W-2100