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(1 � APPLICATION FOR SANITATION PERMIT - [Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereinescribed. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND OCATION- _-Z,1)�------ ._ ------------------------------------------------------------------------------------- i Owner's Nam -------------------------- ------------------- --- - ------------- Phone ------- [ Address_ -------------------------------=-------------------------------------=----------------- ------------•------- ___4 ------ Contractor's - -_-- -_-- Contractor's Name---------------- ----------- Phone- -------- � � ---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -)---_ Number of bedrooms _/---- Number of baths ---)-- Lot size ------!!;' - -_-!!;' d--------------- I Water Supply: Public system Community system '❑ Private ❑ Depth to Water Table,.3-at, l Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)( Hardpan ❑ d Previous Application Made: Yes ❑ NOX New Construction: YesK No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well Distance from fo ndation__._ d------Material_____ _ No. of compartments______ Size_�_� � Liquid depth__�!�- ___'__Capacity____ Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------_ W ❑ Number of lines--------------------------------- Length of each line-----------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of fill te eri -- ------------------Total length------------------------------------- Seepage ---------------------------------_Seepage Pit: Distance to nearestwell --Distant r m.fo ation-- _a_,__---.Distance to nearest lot lin - 1'�__-___ V ] Number of pits------- ------------Lining materi _ Size: D ameter---, --------------Depth__.OQ------------------- Cesspool: Distance from nearest well-----------------Dist nce from foundat- ------r------------Lining material------------------------------------ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.-------_-___-------_-_-_._--_-_--.-____-. Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- + Remodeling and/or repairing (describe):-_ ------..... /f� -------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------•----------------------------------------------- ------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat s, and r regulations of the San Joaquin Local Health District. �of •-----------------------------------------------------------------------------------------------------(Owner and/or Contractor) (Signed) B - - = ----------------------------------------------------------------------------(Title]- t ---- 4 (Plot plan, showing size lot,eael�on system in relation to wells, buildings, etc., can be placed on reverse side). _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- ----------------------------- DATE---------------— ...... Z------- REVIEWEDBY ---------------------------------------------------• DATE BUILDINGPERMIT ISSUED-------------------------------- - ---------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations-------------------------------------------- --- --------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------__1------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- --------------------------------- ---------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY ----------------�_i ----------------------------- Date.t 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 B-51 Revised W-2100