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APPLICATION FOR SANITATION PERMIT Permit No. .......... ..... . �( (Complete in Duplicate) q Date Issued/.Z`__ e.____. _ Applica-lion is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordin nce No. 549. JOB ADDRESS AND LOCATION----.."* .... ,�� -•--•-----------------------------------------------------•------•-- ----- Owner's Name------------------ ------------ ----------------------i----------- Address..... ---------Address.....1�._. . . -- -•--• • ----•--•---------------•---------------....---- Contractor's Name----------------------------------- --- ---- -- -- - --------- ---------------------------------------------------------------- Phone.WW.-/fW/0 -- Installation will serve: Residence Or-'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-1--_ Number of bedrooms __Z Number of baths -_-/--_- Lot size ..... . _sf----_-___-__ Water Supply: Public system ❑ Community system ❑ Private [] Depth to Water Table -Z/-Oft. Character.of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑laT �.� 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_ir Distance from foundation---- p-------- Material__ %T ®� No, of compartments............... J_.__Size.r s_______ ..___:__•Liquid depth__----**-----------Capacity. �Q Disposal Field: Distance from nearest well�Q _Distance from f�tion__/4-1......Distance to nearest lot line--- Number ine._Number of lines....I_-__-__.-_ __ -_Length of each line r-Q-_------_--.Width of trench.... -V-'*'*-------------- n Type or filter mateal...l_J?r._li_ _____Depth of filter material------�_.8__`_�....Total length.-;?-,.D---�__________________________ q � � ' / D Seepage Distance to nearest well-- .-Q--------------Distanc fr foundation.._......._._......Distance to nearest lot lin __/..0..... Number of pits_-_--j---------------Lining materialM-94 .Size: Diameter-_c.cw-----_-.-__-Depth_------C.......__.._....... 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-----------------------------------._-_-_. ❑ 1 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, SM laws, and rules And regulations of the San Joaqui Local Health District. (Signed)--------- --- --- ---------- ------ -------------- ------------------------------------- Aoolmp-mw fer Contractor) By:.............................................................. . ---------- ---- - -�---- ------------------ .-L�_LM——A. -------------.-. (Plot plan, showing size of lot, location of system in re n to wells, build' gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- •--- ----------------------------------•---•------------------••--•---•-•--•---•--------- DATE-�.........................-------•-------- ------- REVIEWEDBY---------------------------- ------ ----------------------------------......................... DATE.-A'------------•-• BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------IFN------------------------------------------------ -------------------------------------- Alterationsand/or recommendations:................. -------------=--------------------------------------------------------------------L!C-------•---------------------------•----------- -------•------------•--------------------------------------------•--------------------------- --------------------•--------•------•--•-•-----------_..._....•------•---------------------------------•--••--•--------------- ---------- ------------------------------------......................................... ...----------------------•----•-----------•----••------•-------•-•-----•-•-----------------------•------------•----...... -----•----•---•----•---•------•--------------------------------•---•----------------...---....-----••••----•-----.....----•---•----------_....._..------------=------------------------•-----------•--------•---•------------- ----------------------------------------------------------------------------------------------•----------------------------------------------------------------------------•------------------------------------------------ FINAL INSPECTION BY:--------- Date / --`'7- - ---- ----------------------------------- SAN 1 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