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N oZ APPLICATION FOR SANITATION PERMIT Permit No. ..... ...... (Complete in Duplicate) j�jj��s____� Date Issued ..._________ ehA'pplica+ion is hereby made to the San Joaquin Local Health Dis rict r a permit to construct and install the work herein described. This application is made in compliance with County Ordinance o. 49. JOB ADDRESS AN C Owner's Nam �/ " "'`"' --- - r- ----- ---------. Phone----- ..— Addres ------- Contractor's Name--•---------- ---- l Phone=/�—� Installation will serve: Residence Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/_-_ Number of bedrooms Number of baths __/._. Lot size -y�4,J� ,.0........................... Water Supply: Public system Community system E] Private ❑ Depth to Water Tab] ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [—] Clay F] Adob� Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YesNo E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic T k: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- No. _-___-_--_---_--_---_--_---___-_-_____- -_-_.No. of compartments__________________________Size--------------------------------Liquid depth--------------------------Capacity--_ Disposal Fi Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_-___-_---_------ • Number of lines-----------------------------------Length of each line-__-__.-__---__-_---_-___-_-_.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------_------Total length_______--_______-__-_______-_-.--_----__._ Seeps a it: Distance to nearest wel _ �ffo �__....._. „�'- Distancdation_ Distance to nearest to line______ Number of pits.-_-_T---------------Lining material Size: Diameter.__--_---.--___-_-Depth__ e- esspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-__.-__.-----__-____._--_-_-_______--. Q ❑ Size: Diameter--------------------------------------Depth-------•------------•-------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------_---------------------------------Distance from nearest building-------------------.----------.---__--_._. ❑ Distance to nearest lot line--------- -------- ---------------------------------- -------------------------- ------------------------------------------------ Remodelin and/or repairing (describ —---- ------------- -------------- ---- •- -------- --------•--•-I•--•-•-------•------•--- ---------------••- ------------ -------._---- ------------------------------------•------------- - -- -------- - -- - --- ----------------------------------------------------------------------------------------------•-----------------..--------------•----•------•- ---- ----------•--------------------------------•-------------•---------------------------------------•------------------------------•-----•------------------•------------------------------••-•-------•--------•------ I hereby certify th have prepared this application and that the work will be done in accordance with San Joaquin County or inances, Sta s nd rul a regulation the San Joaquin Local Health District. (Signed)------ . ........ -- ----------- ----------------------------------------- ----•••--- (Owner Contractor) -------------------------- -- aBy-------------------------------- .---- y Tte ---- -- --------------- - ---------- - ----- -------- (Plot plan, showing size of lot, ocation of system in relation to wells, buildings, etc., can be pl ed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- DATE------------ BY-------------------------------------- � '` ---------••--- ------------- ------------------------------•-------__-•---------------------------. DATE._...-------------/.--- ------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE----------- ----•- Alterationsand/or recommendations------------------------------------------------------•-------------------------------------------------------------------------------------------------•-•--- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- ------------------------------------------------- ---------------------------- ------------------------ ------------------------------------------------------------------------- - ---------------------------------------------- --------------- ------------ ------•--- ----------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:. / ----- Date----1"'1 �' � °5 ----•------------------------------------ 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 '