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APPLICATION FOR SANITATION PERMIT Permit No. . _.fF. . (Complete in Du licate (Com P P ) Date Issued _��1. 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...........a_3 � -s Owner's Name---------------------v -------------� - •-•..` __ Phone_--------------------------------- Address................................................................. ----_---------------------- ............------------------------------------------------------------------------------------------------- Contractor's Name......................................... ......----------- -------•-••---------••--.........--------------------................................. Phone................................... Installation will serve: Residence`,�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/------ Number of bedrooms --"1Qumber of baths _1.... Lot size .... _.l_�__-. _14.0__2 Water Supply: Public system ❑ Community system ❑ PrivateX Depth to Water Table -------- ft. Character of,,soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeK,Hardpan ❑ Previous Application Mader Yes ❑ N16� New Construction: Yes< No ❑ W TYPE OF INSTALLATION ANDSPECIFICATIONS: (No septic ftnk or cesspool permitted if public sewer is available within 200 feet.) S ptTank- , Qistance from nearest well_________________Distance from foundation --- depth --Material_--____-_Capacity------------------------ Disposal .: - No. of compartments------------ t Size---_---------•------------• q p p Y -------------•------ p� Disposal Field: Distance from nearest well__._t Distance from foundation...__ ..�_r_�Distance to nearest lot line__-�._�-,�4. Number of lines........ ':___ _ Length of each line_-"-_ �y____-Width of trench____ UUU Type or filter material_:?__ ,Depth of filter material------_.� . _ _____Total length........ 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-.---------••----•----------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------._-___-_-__-_-_. ❑ Distance to nearest lot line-------------- -•---•----.---•-=---------------------------------•-------•----------=-------•----------•--•----------------------------- Remodeling and/or repairing (describe):-------------------------- --- ----- ---�---••• x -------------------------------------------------------- ------------------------..................... -•--••-•--•-•-••-•-----------•----•--••---------------•------•-••-......--------------•---......-•------............................................................... ----------------------------------------------------- ---------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------------- 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, d rule and regulations of the San Joa :. Lo I Health District. (Si ned 9 �------- --- --- -- -- -- - - - - - -------C•�'�----- --- ---- --- ---- --- -----------------------------------------------------------(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 APPLICATION ACCEPTED BY----- ---------------------------- --------- `"----- ------------}--------------------...• DATE---------- --- s - REVIEWEDBY----------------------------------------------------------------------------------------------- ----------------------------- DATE.--------------------•----•-------•-•-------------•---y BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------_------------ Alteratio s nd/or recommendation •. --------------............................................------ -- ---- -- .. . Vic..... - ------T e I _,� I-, --------------- ce-C.t .! - - --- --------•----------------------------•- ----------------------- ------- •--••---------------- p FINAL INSPECTION BY:-------- ------- ----- ------------------- -----. Date ro 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