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—. . APPLICATION FOR SANITATION PERMIT Permit No.,:�.'-,�- (Complete in Duplicate) �► 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-------------// s►-5�*-/ - . = ' ... -------------------------------------------------------------- ------------- -Name----------------•-------V: /!1 rt Phone Address----------------------------------------------------�-,-,-.-,---- Contractor's Name--------•----•---•----••........ .. ^-----------------------------------------------•------------------•-----••--------------------------------.----- -- -- -- ----------------- -------••---------------------------------•----- ----------------- Phone................................... Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel Q Other ❑ Number of living units: _I__._ Numb r of bedrooms umber of baths . ----- Lot size ._.. ............................ ............... Waiter Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ lay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No ew 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 wellOW DistanTce frogi ,foundation-__•-I.D.,..._..Material . ja�_U-�0.0 _________Capacity_._Al of compartments_._-__--- ________Size... Liquid de th____ ______ Disposal Field: Distance from nearest welry�C. 'Q Distance from foundatio r . .: .. istance to nearest lod.1,*n _.Number of lines-__-____— -_-•_-.-Length of each line_______ �idth of trench--_____-_Type of filter material^-...Depth of filter material------ - -------------Total length___-__._____I.. ....._._.___..._ Seepage Pit: Distance to nearest well-_____--_...__-_-_-_Distance from foundation....................Distance to nearest lot line________________• ❑ Number of pits_____________________Lining material...__ ....__..._._...Size: Diameter------------------------Depth....----------------------------- Cesspool: _--_ __._-.________-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....... ----- Remodeling and/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, tate laws, and rules and regulations of the San Joaquin Local Health District. (Signed)- ...... -------------- ----------------- ---------- -------------------------------- --- Owner and/or Contractor By:................ ..... ••---••--------•--••----....................... ........................................................(Title)_----------------------------------------------------------- (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY PW APPLICATION ACCEPTED BY-----------------------_---- -------------==--- ------ ---------------------------------------- DATE.......... �• - -- •-----•---•---- REVIEWED BY DATE ----------------- •. BUILDINGPERMIT ISSUED..............................................................---...................................... DATE••---------•---••---••---•-------------•--------..._...------ Alterations and/or recommendations------------------------------------------------------------------•---•---------...-----------•---------------...-----•--•-------------•-•--•---•...-----•---- ----------------------------------------------------------------------------------------------------------------------------------------------------------------•---•----------....---------------•--•••---...---•-•-••--... -----•-----------------------------------------------•-------------- ----------------------------------------•--------=--•---------------------------------- -----------------..................................... ------------------------------------ ------------------•-----.-•-----------------------------------------------------------•----•-------------------------------------------•-------------------------------------------••--- --------••----------•------------------------------------- ----- ---- ------- - ------------------- FINAL INSPECTION BY------ --------------• - ----Z. ---- 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