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APPLICATION FOR SANITATION PERMIT Permit No. _ �T (Complete in Duplicate) Date Issued `3 ~ 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 49. JOB ADDRESS AND LOCATfON__ _ (�--_��_.--- SCANNED ---�------- -------------------------------------- Owner's Name____ _________ ___ ------------ --------------- ------- ------------------- - --------------- P A v ;7.p''xx Address-------------------•4_73X.5----------� ------------------------------------------- ---------------------------------------- - KContractor's Name___________ - -------------------------------- ---- ---- ------- 1-------- ---------------- --------------------- --- ------ - --LX 0. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel y❑ Other ❑ Number of living units: ---/___ Number of bedrooms __I_ Number of baths ---�_. Lot size Water Supply: Public system [BCommunity system ❑ Private ❑ Depth to Water Table _X0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0---Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is,availa a w�inW etd Septic Tank: Distance from nearest well_________________Distance from foundation_____ Material ❑ `� No. of compartments__�_-------------------Size---------------------------...Liquid depth------------------------Capacity----------------------- Disposal Field: ° Distance from nearest well_________________Distance from foundation-______•.__________.Distance to nearest lot line____-__--___ ❑ Number of lines ------------------Length of each line-----------------------------.Width of trench Type of filter material______:.--------------Depth of filter material___________ -----------Total length-------------------------------------�--- Seepag Pit: Distance to nearest well_.-------_---------Distance f o fou dation-__-- __ __� OQ C !1______.Distaice to nearest lot --_---_ Number of pits---:---�-------------Lining material C�-6�.,.ize: Diameter----� Q(( ' -----------.Depth------- -5----------------- .� Cesspool: Distance from nearest well----------------- 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):----------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- Q -------- ___________________________ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Iaws, and rules and regulations of the San Joaquin Local Health District. (Signed) .�..., ----------- ------------- ----------------------------------------------------- and/or Contractor) Y� Tale (Plot plan, showing size of lot, location of system in relation to wells buildings, etc., can be(Title) on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___ -------------------- VIEWED BY ----------- DATE-- _ ------------------------------------------------------ -- ------------------------------------------------------------------------------------ DATE--- BUILDING PERMIT ISS_UED---------------------------------------------------------------------------- ------------------------------------------ Alterations and/or recommendations__ DATE ------------------------------------- ---------------------------------------------•------ -- - ------------------ - 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