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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) 3 , Date Issued 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 compliance with County Ordinance No. 549. -------------------------------- JOB ADDRESS AND LOCATION---/--Z-.;?l----- s"r< Owner's Name. ------ Phone---------y --------------- Address----•-------•--X ------------------ Contractor's Name _ - { Phone^�Z-tv (_! ------------- -- Installation will serve: Residence 6-..apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: FNumber of bedrooms _Z..__ Number of baths __: ___ Lot size ___ _ Water Supply: Public system ❑ ' Community system ❑ Private A--DIpth to-Water Table}ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ 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 nearesr well___ _ --___._Dfistance from foundation__ r----Material_______ Q�_ No. of compartments------ ---------------Size_ -- .---X_M_9------Liquid depth__. _ .------------Capacity_ , -O _- --- Disposal Field: Distance from nearest well----XQ_..._Distance from foundation_._./_I0---_-_._.Distance to nearest lot lineta_�.._-_____ Number of lines----------i----jr--ff--- -- _Length of each line------2s4'_�----:-----Width of trench-.-.Z--- ------------------- Type or' filter mate riai._`-,Z_47 Depth of filter material----/S-_`_'_------Total length___14-_, ---r-____------_- Seepage Pit: Dista-ce to nearest well_= (�p_p_-_-Distance from 'foundation___........Distance to nearest lot lineLQ1______.- 1 Number of pits______--_._______Lining material. _2___ '_Size: Diameter-____ ' -I%'� --�-�'--�-•--------------- Cesspool: , Distance from nearest well----------------- from foundation___---_--------------Lining material.__.___---:----_.__._______--------- -Depth _______. �} ❑ Size: Diameter = -Depth----------------------r---------- -------- ------Liquid Capacity----------------------------gals. Privy:f Distance from nearest well----------------------------------- .___-_--_._Distance from nearest.buildin Distance to nearest lot-line- ' - ------ ______ __________ " - ' Remodeling and/or repairing (describe)--------------------..._ --_ - ------------------- -------•----- - -------------- i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a laws, and r les and regulations of the San Joaquin Local He th District. 0 (Signed) k ---(.` ner an o Contractor) --------------------- BY: ' _ (Title)-- Y • - -- ------------------ (Plot plan, showing size of lot, location of system in.relation to wells, buildings,�etc., can be placed on reverse side). 6 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED-BY-------------- "' _ = DATE----- = = - -------------- REVIEWED BY. - --------------------------------------- �� ------------------------------ DATE--------- ----------- BUILDING PERMIT ISSUED -------------------------------•---- -- •-------- - ------ DATE - - -------------- ---------------------- Alterations and/or recommendations---------------------------------- -----•----------••-------------------------------------•---------•------I---------------------------- ---------- --------------------•------------••----------------=-• -------------------•-----------------•----------- -------------------------- ------------------- -•--- ---- --------------------------------------------------- FINAL -INSPECTION BY:.:-:: �'� e --------- ------ 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 r`