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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date issued ---____S_. a�-� 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. SG �G % JOBADDRESS AND LOC TION l- 6 ---------------------------------------------------------------------------------------•------------- Owner's Name------------- ` -------------------- --------------------------------- Phone------------------------- Address ------------=------------------ o 01 Contractor's Name --- ----- -, ---------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Resi nce partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J____ Number of bedroomsc ,.._ Number of baths_______ Lot size . _ �4_d_________________________ Water Supply: Public system ❑ Community system ❑ Private &-<pth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ --.Gravel F] Sandy Loam ❑ �-'-1'f'd Clay Loam ❑ Clay ❑ Adobe Ipan E]� Previous Application Made: Yes Er'-No New Construction: Yes [.}^'I�or❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic k: Distance from nearest well-14-.61^------Distance from foundation---��---------Material---__ i__f+_�___r__�...-_r--------------------- 0► No. of compartments_________�_____--___Size-------------- _-_________-7a________________Liquid depth_____________-___________Capacity Dis osal Field: Distance from nearest well-___�Q--- Distance from foundation/O, ________Distance to nearest lot line.-S--gr Number of lines--------A ---------------------Length of each line_'y�o______` ---------Width of trench_____��_________________ Type of filter material__ -__O___AO_-_Depth of filter material__/_�_______-____Total length--------/____Q2__ -----------------_ 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---------------------------------____. r ❑ Size: Diameter--------------------------------------Depth-----------,-----------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building------------------------------------------ F-I Distance to nearest lot line------------------r------------------------------------------------------------------ Remodel* ------------------------: �► - t Remodelin and/or Dai in 4describe):----___ -ty6 •fie___----+� -------------- -- -- --- - --- --------------- ------------------------------------------------------------ ------------------------------------------------------------------------------------------- ---------------------r------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done irf accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District.' (Signed)---------- ---------- ----- - - ----- - --- - ---------- -- -- ------ ---- _=d#c Contractor) BY� x -- --- -------------------------------------------- (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 - = = ---A--------------------------------------------------- DATE ---�/,� "�r �----------------------- REVIEWEDBY--------------------------------------------------------------------------------------------------------------------------- DATE---------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE------------------- Alterations and/or recommendations------------------------------------------------------------------------ -------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------=-------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------- FINAL INSPECTION BY:--- _ 1.0 Date Z"o > -------------------------------•------ 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 B-51 Revised W-2100