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APPLICATION FOR SANITATION PERMIT Permit No. ...........v .... 7 (Complete in Duplicate) 41.74 / T Date Issued -1_-=�------.---_`f Applica+ion 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.............................. --- -----------•••. Phone................................... Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..1--- Number of bedrooms 2_... Number of baths .1...... Lot size ---2 _?____-,X.._120...___............... Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table V ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe of Hardpan ❑ Previous Application Made: Yes ❑ Not New Construction: Yes JK 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-----$Q------_Distance from foundation------10--------Material____ er�.Gt!!1�-_'_._ No. of compartments_._.-_-._ .Size...... Liquid depth--------9; --------Capacity---_____�__ eA Disposal Field: Distance from nearest well_. .$d Distance from foundation j b _____._f Distance to nearest lot lin�-------�_..._ tp{ Number of lines--__________-_.�.._ Length of each �me..N.0 __+;_40...Width of trench_-__-__.�.' ____________________� Type of filter material----- Seepage ___YD_ftk—Depth of filter material-------4Q'-- -__-:-Total length----------�._V-------=--------------- O 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 -_--.-- --------- 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)--------------• -----------------------------•-----•-------------•-----------------•--------•--•...-•-------_-•... ..................... . -------------------------------------------------•--------------------------•-------------------------------------------------- •------- .......................... -------- --- - I hereby certify that I have prepared this application and that the work will be done in accordance with Sait Joaquin County ordinances, State laws, and )rulers ,and regulations of the San Joaquin Local Health District. (Signed) !.R.---------!�! r+------------------------------------------------ ---Owner and or Contractor By:-- •- - = (Title) (Plot plan, showing size of lot, location of sys in relation to wells,buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------- -- - - -------------------------------.._ DATE............ .. ...r--- ------ REVIEWED BY-------------------------------------------- -- _ - ------------------ DATE.............................. ----------------------- BUILDINGPERMIT ISSUED---................................................................................................... DATE............................................................ Alterations and/or recommendations----------------------------- ---------•----------------------------••--------------•---------------------------•-•-----•------•------------•----••----••------- ..................... . ----------------------------------- -----'--------- ------------------------------- ---- __-..' ------ -- --.I------.........__—..........- .......... - - ------------ d -5 ... �'-�" ------ ------ --------------------------------------------------------------------------------------------------------------------------------------------- ................................................. 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 ES-9-2M Revised W-2100