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APPLICATION FOR,SANITATION PERMIT Permit No. (Complete in Duplicate) / Date IssuedLl _l__ 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 complian with County Ordinance X549. 1 JOB ADDRESS A D L ION-- ---- ._ t ---- -... `.' 7------------------------------'`�C ` ---t--- ' ---- -------£``----`---`� -:---- Owner's Name.____�'_:_._._.__ '" •+-.. r+ Phone_.. Address -' -------- ---------------------------------------------------------------------------------------------------------- ----------------------------------------- Contractor's Name.... !I, " `I -------------------- -------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence [Apartment --House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ ther ❑ Number of living units: ---/--- Number of bedrooms --i.- Number of baths __I_-- Lot size; _ _ '; _--------------------------------- Water _______________________________Water Supply: Public system [Jtommunity system ❑ Private ❑ Depth to Water Table -------- ft. W Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adobe [r]'/Hardpan I-]-� Previous Application Made: Yes E] No New Construction: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet) �%i� Septic ,Tank: Distance from nearest well�k Distaa #ro fo ration 1l `ateri ___ __.__ _.� No. of compartments____:-.___ ---�.-__ Size_ ___�___=-.Liquid epth_______ __________ Capacity___(. Dispos Field: Distance from nearest well-MV-------Distance from foundat' n./_O.__ Distance to nearest lot ine__........ Number of lines___________-------- Length of each line__`-47s _ Width of � _ material r� trench.__________r epth of filter material-.._ f�______- otal length__._-___.___ _� _T____' _____________Type of filter materi A 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---------------------------------------------------------------------- Remodel►fig aril/or repairing (describe ----•--_C 7.r £°*ate ---- •--- -------------------------------------•--------------•----------------•--------------------•--------------------------------------------------•------•---------------...._...--••-----------•--------•---------------•-------- --------------------------------- ---------------------••-------------------------------------------------- -----------------------•-------------------------------------------------------------------------------------- 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, �Iesn regulations of the San Joaquin Local Health District. (Signed) . --------- '-` �'r'- t - (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- ----------------------------------------------------------------------------------------- DATES`— - - REVIEWEDBY------------------------------- ----- - ------------------------------------------------------------------------------ DATE -c BUILDINGPERMIT ISSUED-----------------------------------------------------------•--------------------------------------- DATE---------VN------------ ------------• -------------- Alterations and/or recommendations-------------------------------------------•-•---------------•------------------------------------•----------------------------------------------------------- -------------------------------------------- --------------------------- --------------------------------••-------------------------------------------------•----------------------------------------------------------- -------•------------------•------------------------------- -------------- ---------------------- --------------------------............----------------------------------------------------------------------_--------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------- ------•-------------------------------------------------• ------------------ --------- --------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:--------- Y_ -2Q-_-\,. -_...__ \) " I3 " 'r S 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