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Permit No. APPLICATION FOR SANITATION PERMIT _.__....._ .. 1 x 'TN (Complete in Duplicate) r Date Issued Application is hereby ma t 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 Or inance No. 49. JOB ADDRESS AN LOCATION....__/ _S _ _ Owner's Name ----- ------- �L�i - ----- -- --------• ------------------- -------------------------------------------- Phone---'��- --�--rd... Address-----...........7.0-_15. /�...----�.............. --- --/--.. ------ ------........................................... ----------------------------...........q....-----------------.... Contractor's Name------...0-- �✓ . - ---------------------------------------- Phone..!._'"�t_-Z4-t....... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel ❑ /Ot�h•-e-r El-_of living units: ___�__ Number of bedrooms __�r- _ Number of baths ---.�__ Lot size ----Le jq_,X__1___1' _-___________________ Water Supply: Public system [Community system F] Private F] Depth to Water Table .y0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe M---/Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ - 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-----------------Distance from foundation....................Material-_.-_______________-__-_-._-_----__--__-___-__--. ❑ No. of compartments-------------------- -----Size--------------------------------Liquid depth--------------------------Capacity--------------------� Disposal Field: Distance from nearest ell.._ _____--._- _ i ante from foundation-----/_ -------Distance to nearest lot line---A 0..... [r Number of lines ..---_-_- _ ength of each line------ _ Width of french____-- - ----- - ----------------------- - Type of filter materially--�_____.___ __-_Depth of filter material_____ZI--_-____Total length........�_Q_�_________________________ 1 f � Seepage Pit: Distance to nearest well ___ -------Distance from—foundation____. .......Distance to nearest lot line__._ --- Number of pits--------I___________Linmg material.4_�s_ 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------------------------------------------------------------------------------------------------------------i�----------------------------- j9delig and or re tdscribe) ` ________ ___________________________ ____ ______________________________________________________________________________________________________________________________________________________________________ I hereby certify that I have,prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I ws, and rules and regulations of the San Joaquin Local Health District. 1 Si ned _. I_. ----- _ ------------------- 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 ACCEPTED BY------------_------------ -------� ----------------------------------------- DATE--------- _ REVIEWEDBY--------------------------------------------- ------------------------ DATE-------------------_--------.............................. BUILDINGPERMIT ISSUED------------------------------------------------------------------------------_-------------------- DATE----------------------- -- ---------------------------------- Alterationsand/or recommendations:----------------------------------------------------------------------------------------------------------------------•-----------------------------------_ ......................•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------- ------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------- ----------.................................... ------------------------------------------------------ .........................................----------------------------------------........ -----------------------------------------------...----------------------- -------------------- ----------- ------- ---- -------- --- ------------- ----------- -------------------• -------------------------------------------------------------- - FINAL INSPECTION BY:. y Date y f- - 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 10-52 Revised W-2100