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APPLICATION FOR SANITATION PERMIT Permit No. __-____ (Complete in Duplicate) Date Issued --------_--S� Application 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. JOB ADDRESS AND LOCATION__._ _�_ _-----__ ---_- , ------------ Owner's Name------------ ----•- ------------------------ Phone---- ------- - -------------- Address ---------------•-----�,-.-.��-- ---•--- -----------•-------------------•--•-----------------.-.----------•----------------•------------------•------------------•---------------•------------ Contractor's Name... .rX -------------------------------------------------------------------------------------------- ----------------- •--- Phone Installation will serve: Residence-;d- House ❑ Commercial ❑ Trailer Court ❑ Motel Other Number of living units: __ ----- Number of bedrooms -- Y Number of baths ----(__ Lot size ___ _t7 e------__-------- 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-VHardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yesbff 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 foundation___--_-______---___.Material_- /� No. of compartments-- ------------------ ----Size---•----------------------------Liquid depth-------------- - --------Capacity--------- - isposal el Distance from nearest well..--__-._.---- Distance from foundation------------------ Distance to nearest lot line------ Number of lines-----------------------------------Length of each line------------------------------Width of trench.-------------------____-- ` 1 Type of filter material----------------------- Depth of filter material-----------------------Total length----------____-_-_____-__-_ Seepage Pit: - Distance .to,nearest well _pkA Distance fro foundation-___&_��_______-Distance to nearest lot fine ..� ° Nu'm`°br of pits------- -------------Linin material__- . ze: Diameter__._ Deptn___ - __ g - --._ -------------- Cesspool: ' Distance from nearest weil-------------_---Distance fr m foundation--------------------Lining material____.-____--- .______--___.--- - -- ❑ Size: Diameter --------------Depth---------------------------------------------------Liquid Capacity-- ------------- --------- gals. s= Privy: Distance from nearest well-----------._____."",_,---------------------------Distance from nearest building-------------.____-- xx ❑ Distance to nearest lot`line ' ---------------------------------------------------- f�3 Remodeling and/or repairing (describe)_---_------------------------------____--___.___ % ---- ------------------------------------------ ----------------------------------------..---------------------------------------•----------------------- -----------------•--------- ---------------------- ------ -r----------------------------------------------------- t --------------•------------------- - ---------------------------------------------- --------•----------------------------------•----------------------------------------------------------------••------------------------------------------------------ - ------- �1 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)--------------------�= ----------------------------------------------�----------•--------------------- -------------------------(Owner Contractor) tor) By:---------------------------------------------------------------------------------- ------------------------------- ---- ------------------------------------(Tif le)---------- ----------------•----------------- ------------------ (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-------•---- --------------�41�1= ---------------------------------------------------------- DATE------ ------------------------------- ---------------- --- REVIEWED BY I-�--�---------- ----- DATE---------- BUILDING PERMIT ISSUED---------------- '---------------!1-7"-- -------------------------------------- ------------------ DATE-------=---- Alterations and/or recommendstions________________________ -- - ----- _ ------------------------- " --� �_�._ Q C ------ ---- ---- -------------- - --------- Y~ ------------•-------•----- ------- --------------------------------- ------ - r ------------------------------------ ----------------------------------------------- ------ FINAL INSPECTION BY:. �h� Date '- ..(. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ' " 300 West Oak Street i32 Sycamore Stree+ 814 North-"C'-' street f Stockton, California Lodi, California Manteca, California Tracy, Califoieia ES-9-2M TO-52 Revised W-21 oo _