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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �� G / `A Date Issued 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--------- �Q C ---------------------------------------------------------------------------- Owner's Name -----------•--- ---- ------------------------•-------------------------------- ------------------•--------•--- - ----------------------------- --------------- Phone---Address-----------• 1OO --------•-------- -- -----------------------------•------------••----------••-------------•------------------------ Contractor's Name------- -_ r� - - - - ---•- ----•---/�-"�� --------------- Phone----- -•-•-��--- --------- "� --------------------------------------- Installation will serve: Residence Rr Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -4 Number of bedrooms ---A Number of baths ---/. Lot size ------Sd_- .Z-�► d Water Supply: Public system ❑ Community system ❑ Private1' Depth to Wafer Table 3.0 ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)" Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YeX Nod' 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_Za�_O-----Distance from foundation......_ dNo. of compartments__________ __________Size_ --------Material--------------------------------�-- a--------- a" _ qudepth------- __-- .. --Capacity---isposa Field: Distance from nearest well.. - --__-Distance from foundation.__ -- .-__Distance to nearest lot line ---2�rf_------� Number of lines------------I_-.____--__--._.__Length of each line________.2_-S_--- Width of trench_--.__ .`�"---------------- a Type of filter material___S-�n c�--Depth of filter material____�fl-'-1__---_Total length__--__,�_-��-------------•-- -•- -- Seepage Pit: Distance f nearest weft_.- QD--�---Distance from foundation___/�------.Distance to nearest lot line----------------- _ Number of pits.-----1_ Lini ---------- ng material_ -. Size: Diameter------3--16-----------Depfh------- -Q Cesspool: Distance from nearest well-_______________ Distance from foundation---------------_ . Lining ma#erial----------------------------- Size: Diameter--------------------------------------Depth_ ------ ------------------------------------------ Liquid Capacity--- ----•--gals.{� Privy: Distance from nearest well------------- ---------------- El Distance to nearest lot Distance from nearest building line______________________-_- ------------------------------------------ -------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ -----------------------------------------•------•------------•----------------------------------------------------------------------------------•----------- - ----------------------------------------------- I hereby certify tha+ 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)-------••----------- G:a _�_�__ i - -( ner and/or Contractor] ------- -------- -- ---- ------------------------------------------------------ --------- BY: ------(Title)-- (Plot plan, showing size of lot, location of sysrem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-__.--__.________________ f ---- -REVIEWED BY -- DATE----- - ------------------ DATE--------------------------- ---------------------------------------- UILDING PERMIT ISSUED-------------•�------ - - -------•----------•----------- - ---•----------•-------------------------------------------------------------- DATE Alterations and/or recommendations---_____---_------------------ -----------------------•----------------------------------- ------------•-----•------ -------------------------------------- ------------ - FINAL INSPECTION BY------------------- ------------ Date--------------- � (k d ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100