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APPLICATION FOR SANITATION PERMIT Permit No. . .L. ..._l__ (Complete in Duplicate) Date Issued Application is here y made to the San Joaquin Local Health District for a perm' to onstruct nd injst�II-the ork h,jrein described. This.application..is-madean,compliancetwith County Ordinance No. 549. X ��„•„ 04 JOB}ADDRESS AND LOC_ ION__ ---- -- k- ,?_--------------- ------ 'k---�' -- - -- --- - - - Owner's Name------- -- ----- ------- ------- Phone---- � -_.lf •J Address.------(1_ --/- --} — - _ J Contractor's Name. G �' �L----- ---------------- Phone---/ '{ -------------- Installation will serve: Residence 21-<partment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .__,___ Number of bedrooms -A— Number of LL//aths ._I-_- Lot size _b_ _'__X_--d�0'_Q--i-----._- ----- I Water Supply: Public system E] Community system Elate PrivR Depth to Water Table :T�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E) Clay Loam ❑. Clay ❑ 'Adobe Hardpan ❑ 1 Previous Application Made: Yes ❑ No B-'�New Constructio : Y s No �_ C 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 _____.-_____.__Distance from foundation--------------------Material _____..________.___-..________._-__.._____--___. ; ❑ No, of compartments. Size Lii .1quid depth Capacity ------------------ Disposal-Field: Distance from nearest w I ..__._Distance from foundation______�� _ __.Distance to nearest lot line;--__` Number of lines____________ __ __ Len th of each line______ Width of trench.._._�_� Type of filter material__/ ..- .___Depth of filter material__.____ -----------Total length_______ ___-------------------- Seepage __________________ 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------------ ----"------------------:.Depthr-------------------------------=-------------- ---Liquid Capacity- gals. Privy:. m Distance from nearest well-------------------------------------------------Distance fronearest 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 San Joaquin'County ordinances, State laws nd rules and regulations of the San Joaquin Local Health District. (Signed �-- - .---------------`1-y� -'--------------------- --------------------------------------- ------- Owner and/or Contractor)------------------ By:_...--------------- --- ------------------------- ----(Title)----- - ---------------- ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can beplaced on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ --------------- --- ----- -------------------------------------------------- DATE--------------- { REVIEWED BY DATE----- ----------1 -------- BUILDINGPERMIT ISSUED------------------------------------- --------------------------------------------------------------- DATE-----------------------------=----------------=----- Alterations and/or recommendations-------------------------------------- -----------------------------•---------------- ----------------------------------------------------------------------------------------------------- ---•------------------------•------------------._-._.--------------•----------.--------•--------------------- ------ - -------------------------------------• --------------------------------•--------------------------------------------------------------.-.------------ ----•--------•------------------------------•- --- -----------------------•---•--------------- ---- -----------------------------•------------- -----------------.- -------------__-------------------------- I 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 10-52 Revised W-2100