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APPLICATION FOR SANITATION PERMIT Permit No. _______ ___ _________ 41( (Complete in Duplicate) 3 '1� Date Issued ---- -----------__-_T gplica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thiapplication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND OCATION---- -- -o-- --------------------------------------------------------------------------- Owner's Name--------- ------------ ----•----- ---•--•- - -----•-••--------------------- ------------------------- ----- Phone-20 - ------ Phone ---•�FQ ------- Address-----------------�i7lry4 -------------- ---------- -- --- Contractor's Name-------.- - "-�- .r-------- . -------•--------•----- ---------•------------------ -------------- Phone--y~-�-4-A-7----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms ---f_-_ Number of baths __ __. Lot size ___ _+ _-7 Water Supply: Public system [[Community system ❑ Private ❑ Depth to Water Table _ d_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R-1kardpan ❑ Previous Application Made: Yes ❑ No LA New Construction: Yes E�r`No ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic 'rank: Distance from nearest well---------__-Distance from foundation------/ --------Materia4__.e_�J�-"_-__----_. _-_�_. ---. - p ---------._Size---�------�� -��-•Liquid depth----- ------- - ---------Capacity---------------------- No. of compartments Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_----_---_-_---._ [�•j �I"`� Number of lines-----------------------------------Length of each line--------------------- ----.Width of trench.---------------------------------- W `°� Type of filter material-------------------------Depth of filter material-----------.,-----------Total length_--_-_------_--_-.----_--------_ 11n Seepage Pit: Distance to nearestell--------` -------Distance from foundation------IS......Distance to nearest lot line-__-_/`�___ [►]� Number of pits_______ ______________Lining material--- -_:._ - Size: Diameter____ ��_..____Depth.__ ��r___---______--___-- S a Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--.---------------------------------- 11 Size: Diameter---- ---------------------------- ----Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearesr building ---------------_-_-___ ❑ Distance to nearest lot line----------------------------------------------------------------- ------------------------------------------------------------------- NA Remodeling and/or repairing (describe):---------------- -----------------------------------------------------------------------------•----• -----•-------------------------------------------_ --•--•---------------------------------------------•---•---•--------------•-------------------------------•-------•------•---•--------------------------------------------------------------------------------------- -------- ------------------------------------------•--------•----••---------------------•--•-----------------•-------------------------------------------------------------------------------------------------------------- h 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)---------------------- - - - -4 -------- ---------�-�`'`'L/+-------------------------------------------------------------'---------( ftr and/or Contractor) By:-----------------Z--------- ----------------------------------------- -----------------(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------------------ = - ---------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE--------------------------------- --- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:----------------------------------------------------------------------------------------------•-•--------------••--•------------------------------------------ -----------------------------------------•---------------•--------------------------------------------------•----------------.----------••----------------------•-•---•---•--••----------------•------------------- -------------------------------•------------------------------------------------------------------•-----------------------------------------•---- .....................------------------------------------------------------ ------------------------------------------- -•------------------------------------------------------------------...----------------------------------------------------------------------•----------------------------------- ------------------------------ ------------------------------------------------ ------ ------------ -•-------------- ------------ ----------------------------------------------------------------------------- �g�11 Z —Z7 .J � FINAL INSPECTION BY---------------- ---------- --- ------- ---------------------- Date-------------------------------------------------------------------------------- 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 4 ES-9--2M ; Revised W-2100