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APPLICATION FOR -SANITATION PERMIT Permit No,,21_l___?_a___ (Complete in Duplicate) Date issued/1- Application ssued/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 P5diinance l o 549. rr JOBADDRESS Ag� OCAT*ONN __ __ 1_ .___!____'_ __ ----------- -------------------------------------------- --- -Owner's Name------`-- -- -- - -•- ---------- ----------- ---------- --------------------------------------------------- Phone-------- Address----------------`-Z--- ---- ------------------------------------------------ -----------------------------------------=------------------------- Contractor's Nam = Phone -•- --------- --- Installation will ser Res'sdence u A. tment Hausa ❑ Commercial ❑ Trailer Court ❑ Motel,❑ Othe' ❑ �0 P Number of living units: ___it____ Number of bedrooms __�___ Number, baths _4"'__ Lot size __________________________________ �__ -__-____ !, Water Supply: Public system 0 Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of.3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 7 New Construction. Yes 5No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public- ewer is available within 200 fee+.) Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material_________________________________________________ ❑ No. of compartments--------------------------Size-----------------------•------- Liquid depth-----=--------------------Capacity--------------:-------- Disposal Field: Distance from nearest well_________________Distance from foundatio.n______= ------Distance to nearest sot line________________ ❑ Number of lines-----------------------------------Length of each line--------------------------------Width of french----------------------------------- Type of filter materia------------------------- of filter material-----------------------Total length_________________________---_--_-___-____ Seepage Pit: Distance to nearest well__ --___ ___Distance from foundation--------------------Distance to nearest lot line-------.---__-_-_ ❑ Number of pits----------------------Lining/material-----------------------Size: Diameter---------------------,Depth_1?_ -- _-- Cessp 'I: Distance from n wrest Well�Q __-Distance frosts foundation..--L-_r�_-__-__-Lining material-__pUf --!__ SAg C ize• Diameter_ ► �-_X5 E3-I�. _Depth ___C __-- ________________ Li uid Capacity gals. Privy: Distance from nearest well_________________________ ________ _ _________Distance from nearest building_____------------------------------------ ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- ( Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- ----------------------•-----------------------------------------------------------------.---------.----------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 of the San Joaquin Local Health District. (Signed)-- ---------PA1XV-__j -----------------------------------------------------------------------------(Owner and/or Contractor) by=----------------------------- ---------- ------------------------------ ---------------------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in rela to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --------------------------------------------------------------------------------------------- DATES REVIEWED BY---------------------- ------- --------- - DATE--- .tea ------------------------------------ ---------------------------------------- ---------------------------------------------- BUILDING PERMIT ISSUED----------------- -- ----------------------------------------- ------------------------------ --- DATE -� �------------------------------------------- ------- r Alterations and/or recommendations:---------:------------------------------ ----------------------------------------------------------------------- -------------------------------------------- n------------------------ ---------------------------------------- . � ^�- ` - ---------------------------------- ------ -=----- --------------- - -- -- 1- -- .- "---- -------------------------------------------------- FINAL INSPECTION BY:---------- -------- ---------------- ---------------------- Date----- . '--- , -------------------------------------- � SAN JOAQUIN LOCAL HEALTH DISTRICT l 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9=2M B-51 Revised W-2100