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t t (Ae' Permit No. ....................... APPLICATION FOR SANITATION PERMIT �"' (Complete in Duplicate) _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 Countygpdinance No. 549. I f JOB ADDRESS LO , ION !_ �= --- = -------------------------------------- Owner's Name A - ---•------ Phone f� ............. Address--------------- .. '�-`.. . - ----------------------------- ------ - ------•------------•---------------•------------------------- -------------- Contractor's Name-------------- --------- ----- ------------------------------•-------------------------------------------------------------------------- Phone.................................... Installation will serve:. Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .- _._ Number of bedrooms .../_..'Number o aths ...L Lot size___7-PA-c3-19L,!_!e4_L,!__-_s --____-••---._--.-- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ........ ft. Character of soil to a depth of 3 fee Sand Gravel Sandy Loam Clay Loam ❑ Clay E] Adobe�ardpan 0 Previous Application Made: Yes 7 ❑ E]No F1 New Construction: Yes o ❑ - TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No,septic tank or cesspool permitted if public jewer is available within 200 feet. "►► Septic ank: Distance from nearest well -.. !_...Distancep from fo�u�nd^alion...I__ _....__..Ma rial---_ _ ------ ....•... No. of compartments------------ ----Size-857X 1J9..)t__--Liquid dep h-------------------------Capacity----I Dispo Field: Distance from nearest wel ________________Distance from foundation Distance to nearest lot li e�.f 7 ------ Number of lines..... _..V...........Length of each line_______•-•-_-___/�_ f----..Width of trenchf.__ ____ !t'............. Type of filter materia ---- L K.1)epth of filter material_.__---!_ _.......Total length_____!,? _ _____________________ Seepage Pit: Distance to nearest well---------------------- 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................................................ ................................... Remodelingand/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, and rules and regulations of the San Joaquin Local Health District. (Si nedr----IN-4 -- - - (Owner end/or Contractor) -------------------- By: --- --- - By--------------------------------•-- ------ --------------------------------------------------------------(rifle)------------------------ --- ------------------------------- (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_. DATE _............................................ REVIEWEDBY------. •------------------- . ------------------------------------------------... DATE------W-' ----------------------------------------------- BUILDING ------------------------- .---- --------- ---------------- BUILDINGPERMIT ISSUED---...------ --------------- ------------•---- `-----------------------------_..... DATE-------_.. ----------------------------- Alterationsand/or recommendations-------------------•--..................--................................................................................................................... -------------••----------•----------------------...............................................-............................................................................................................................ ---•-- ----- --- -----------------------•------------------------.....------...............................-------•---------•-- -----.............................------ FINAL-INSPECTION BY. r= Date_..-•------------ � !'�I 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