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APPLICATION FOR SANITATION PERMIT Permit No. __a--3_a-t'___ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and insfall the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION- _�_ --------------------------------------------=---------•----------------------------------- F Owner's Name------------ Phone !� I Address-------------=------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- Contractor's Name---------------. °, t '------------------------------------------------------------------------------------------ Phone---------------------=------------- Installation will serve: Residence r partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A____ Number of bedrooms/__ Number of baths _!_----- Lot size --------- �------------------ Water Supply: Public system Community system ❑ Private>< Depth to Water Table ________ ft. Character of soil to a depth of Seet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe Zj--Htrrdpan ❑ Previous Application Made: Yes ❑ No� New Construction: Yes,X No E] Q, TYPE OF INSTALLATION AND SPECIFI.CCA-TIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ptic_Tank: r Distance from nearest well_________________Distance from foundation---------------------Material------------------------------------------------- No. of compartments------------- --- -----Size--- ------------ --------------Liquid depth-------------------------Capacity-------------------- # Disposal Field: Distance from nearest wem+__�W-fts'ance from foundation----1_0--- ____-.Distance to nearest lot line_____ Number of lines-------- --�- --- ---- ---Length of each line------_-__-- -�----------Width of french----_-�Lf l/----i�------- De th of filter material_._ to -----Total length------- _ __Q_________________________ Type of filter materEal___ lam-- ___ p ------ Seepage Pit: Distance to nearest well ______-Distance from foundation-------------------Distance to nearest lot line_________________ ❑ Number of pits____1----------------Lining material----------------------Size: Diameter-----------------------.Depth--------------------------------- .1 Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------------------------------------- 0 Size: Diameter--------------------------------------Depth----------------------------- ------------ - ------Liquid Capacity----------------------------gals. Privy: z istance:�_f:rom_nearest well-------------- ------------- --Distance from nearest building------------------------------------------ _r,'��rest .- - --------- Distance to nearest lot line--------------------- --------------------------- " Y Remodeling and or,repairing ( escri ) - -------- -� _ - "� - -- ------ -----�� ----- I-�-------------V1.0- ------ ------------. ---------------------------------- --------- -------------------------------------- ------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations ofrthe San Joaquin Local Health Distric+. (Signe _- f_ u -.--_= .. -" ----- ----------(Owner and/or Contractor) $ ----- ------------------------------------------ ------------------------------------------------------------------- (Title) - {Plot p! n, 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-------- I -------------------------------------------------- DATE--------- , REVIEWEDBY---------------------------------------------r-------------------------------------------------------------------------------- DATE------------------------------_ .---_--•-•------------- BUILDING PERMIT ISSUED---------------------------------------------------------------R------ ------ DATE--- -------------------. - ---- ---------- Alterations and/or recommendations:-- " °�,a�' g'`f K_?---' �--"-------- _��-------*__I--•-------------------------- f ________ _______________•.______________________._-.._._____._____--__-_-___-.._-_________.____________-- _-__---___ _____________-___________.___-_ _ ____________-___-________________--- - ______ ________________-__________ { _ ____________________________________________________________________________________________________-__________________ FINAL INSPECTION BY:.- �' ------------------------ Date ------------- �- v 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 8-51 Revised W-2100