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APPLICATION FOR SANITATION PERMIT Permit No ---___--_ (Comple+e in Duplica•te) Date Issued 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 N . 549, JOB ADDRESS AND LOCATION________,__ __ --------------------------------------------------------------- Owner's Name 1�- r ---- ---- - --- ---- ------------------------ ------------------------ Phone------------------------------------ Address ------------------ ------ -------------------------------- ----- i Contractor's Name l :,C_ -------- Pho Installation will serve: Residence Apartment House, El- -Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 4F- Number of living units: _ ___ Number of bedrooms __ Number of baths ___/___ Lot Isize ---__�`__�_0 � __ __ _______________ Water Supply: Public- system Community system ❑ Private ❑ Depth to Water Table ft. - Character of soil to a depth of 3 feet: Sand ❑ Gravel 0f- Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe Ed,-H-ardpan ❑ Previous Application Made: Yes ❑ No Ej--"New:Construction: Yes Flo ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS + - i J ��` (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) _V Septic Tank: Distance from nearest well_________,_______Distance from foundration-_.____-___--i---.Material__________________________-__'_______----_--_- ❑ °S No. of compartments-------- -------- Size--------------------------• --Liquid depth--------------------------Capacity----------------------- rr-77� ` Disposal Field: Distance from nearest well___ ^f____.Distance from foundation____�_�.__�__._Distance to nearest lot line__�_�r ❑ Number of lines------:/------------------t-------Length of each line_!.3 6 --- ----.Width of trench------a-- - -------___----- Type of filter material__-____I.____________ epth of filter material____ .0� __Total length------. __ ___________________________ Seepage Pt: Distance to nearest well_ _�I-,Q _____Distance from four tionI.P_____ ____.Distance to nearest lot line___--_ Number of pits--- -_ sk------.Linirig material_ ____-� E � Size: Diameter______ Cesspool: Distance from nearest we11_________________Distance.from foundation---------------- Lining material______________---.--------_ ❑ Size: Diameter_ depth_, - -; F Liquid Capacity +- - Is. Privy: distance from nearest well___" ------------------------- __ #_ .:- '______ _Distance from nearest building--------------------------------------------- Distance to nearest lot liney ❑ H_:_»r ..: _•__ ��; r `` -'-------------�----------- -------------------------------------------------"---- Remodeling and/or repairing (describe):---- .� _ ------ ------- ----------------------------------------------------------- T _______________________________________________________________________ _______] _____ ----.--------_------------------------------------------------------------------------------------------------------------------____..------- 1 hereby certify that I have prepared this,applica+ion and that the work will'be done in accordance with San Joaquin County ordinances, State laws, and rules and regul'ations of,the San Joaquin Local Health District. (Signed) ---____d_ -� _ - ----- --------_ ner an or Contractor 9 fr -------- --- - = E � l - - ---- ------ By:------------------- 5 ------------------------------(Title) --- ---- -------_—--:-------- (Piot plan, showing size of lot, location of system in rela+ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY " f APPLICATION ACCEPTED BY----- -------- DATE = REVIEWED BY---------------- -L� -}r ;'S ------------------------- --------------1------- -------------------------- ------.DATE----------`--------- BUILDING PERMIT ISSUED---------------------------------------------------------------=--------------------------------:----- DATE Alterationsand/or recommendations:------- ----------------------------------------------------------------------------------------------------------•----------------------------------- ------------------------------------------------•-- -------------------------------•-- ---------------------------------------------------------------------------------- ------- ------- ------------ ----- ----- - -- - --------------- ------ •-------------- ----------------------•-------------•-------------------------------------------------• ---------------------------------------------------------------------------------------------------------- 1 FINAL INSPECTION BY:__'1111!! -& 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 i ES-9-2M 8-51 Revised W-2100