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APPLICATION FOR SANITATION PERMIT Permit No. �\ (Complete in Duplicate) 3 / Date IssuedS______ 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION---- -�----- --- - dy i---t--yt �j Owner's Name----------- ---------------- -----•-------•----------------------------------------------- Phone-----------------------_---------- Address7 (r ,` ----------------------------------------------------------------------------------------------------- Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone................................ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ IvjotelOther [Rr Number of living units: __l-__ Number of bedrooms -5-"-. Number of baths ',l/_ Lot size ___ _ _ [ ............................... e Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand Ej Gravel ❑ Sandy LoamK Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes.❑ No 5?/ 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_0v _ Distajefrom foundation_-A�----------_Matejial-. "�_r___________________ ® No. of compartments-._2 r_-____ -------------- Disposal __-.-___Liquid depth______-_--._________Capacity__��____- _ Disposal Field: Distance from nearest well_/,&0_'__-_Distance from foundation_��__�j V_-Distance to nearest of qe_____ .......... 0 Number of lines______ __________ Length of each line Q__!a1 P----.Width of trench__ //�� / r------------------- Type of filter mate ria l__3'•dZit- .---Depth of filter materia___W!==------_Total length-----/_4040----------------------- Seepage Pit: Distance to nearest well----------------------Distance 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-------------------------- ----•--------------------------------------- ------------------------------------------------•-------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ -------------------------------------------------- ------------------------------------------------------------- 4 ---------•------•--------•----------------------------------------•-------------------•--•-----------------------................. -------------=------------------------------------•-------------------•------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sjqfe laws, and rules and regulations of the San Joaquin Local Health District. "inreltaf;ion -------------------------------- --------------------------------------(Owner and/or Contractor) By:----------------- ------------------------------------ -------------------------------------......(Title)------------•=---'----- ---------------------- ---------------- (Plot plan, showing size of lot, location of swells, buildings, etc., can be placed on reverse side). RT T USE LY APPLICATION ACCEPTED BY.---,,/7_-_ -- _ ....... DATE---- __ ________---------------------- REVIEWEDBY---------------------------------------------------------------------------------------------------------- ------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED..............--------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations------------------------------ ---------------------------------- ----------------------------•---------------------..__.---'--------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------'--------------------------------------------- -----------------• ----------------------------------------------------------------- -------------------- -----------------------------------------------------'----------------------------------------------------- -----------------------------------------------•-----------------------------------------__------------------------------------------------ ------------------------------------------- ----------------------------------- ------------------------------------------------------------------------------------------------------- ----------- ------------------------- --------------------------------------- FINAL INSPECTION BY:. ------ - 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 10-52 Revised W-2100