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APPLICATION FOR SANITATION PERMIT Permit No. 0( 4__d_ (Complete in Duplicate) ! Date Issued Application pp n 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 Ordi nce ,No. 549. JOB ADDRESS AX!,.fft 8__q LO TION__________ ___ ------------------------ Owner`s Name----- ------ ---------------- Phone . ---------------------------- Address----- -------r e._.(tI - .. -------•------------------------------------------------------------------------ ----- - Contractor's Name ----------- Phone------------- p ❑ Installation will serve: Residence A ai-tment House Commercial ❑ Trailer Court ❑ Motel ❑ Other [) Number of living units: -_1---- Number of bedrooms __Z_ Number of baths ---____ Lot _ ---- Water Supply: Public system ❑ Community system ❑ PrivateDeVth + Water Table !-V_ ft. A Character of soil to a depth of 3 feet: Sand E] Gravel'❑., Sandy Loamlay Loam I—] Clay E] Adobe El Hardpan E] Previous Application Made: Yes ❑ No New Constructid67Yes [/No [❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fe Septi Tank: Distance from nearest well Disty& f _ _froounion_____ Materia+ No. of compartments--__-______!� -________ F Capacity_ - �_ - Liquid depth------------- �-Gn- ----- _ DispI Field: Distance from nearest well__ ._.Distance from foundation--___ --- - �----- � i�-____-Distance to nearest lot li er__-_--_-_---- Number of lines------------- -1- _-__-__-__ _Length of each line--_---1-_ -0 _-r Width of trench-__9 - Type of fitter material- --�'�Depth of filter material---------I-- ------Total length-------1.6ts -------- -- eepage Pit: Distance to nearest well----------------------Distance from foundation_------__---------.,Distance to nearest lot line-_-____--__--___ � v r. k ❑ Number of pits-v- -YLining_:tea#srial = size: Diameter--------------------'-Depth------------------- ------------ Cesspool: `Distance from nearest well-----------------Distance from foundation- ___-_.----.Lining material__---_----__-_-----___--_-_-_- ---•- ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid Capacity---------------------------------- Privy: ------gals. I Distance from nearest well----_-_.---_____________________-.---- ---_..Distance from nearest builclin ❑ Distance to nearest lot line_____________________________________________ -------------------------------------------------- Remodeling and/or repairing {describe)------------------------------------------------------------------------------------------------------------- •-------------------------------------------•----------------•------- 1 ------------------------------------------------------------------------------------- -------------------------------------- -----------------------------------•-------------------------------------------•----------------------------- --------------------------------------••-------------------------------- ----------------------------------------------------------•------------------------------------------------------------------------------------------------ ---------------------------------------------------------------- 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, an rules and regulations of the San Joaquin Local Health District. (Signed)---- ----------------------------------- ---------------------)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 ACCEPTFD BY- ------------------ ----------------------------------------- --------------- DATE__ REVIEWED BY-- --- ------------------------------------------------- . --------- ----------------------------------------------------------------------------- DATE- - j__- ------------------------------------------- UILDING PERMIT ISSUED-------------- ---------------------------------------------------------------------------- DATE--------Alterations and/or recommendations:--•------------- -- -------------------•--------------------- ---------------- ---------------------------------•-------------------------------------------•-------------------•--------------------------1- ------ -----•---------------------------------- ------------ ------------------ ---------------------------------------- - - 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 8-51 Revised W-2100