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APPLICATION FOR SANITATION PERMIT Permit No. ..-f---- �\A f�lCom lete in Duplicate} P 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--------071j 07,94,--- _4- 0 ----------------•- ---------------------------------------- ------- Owner's Name-------- -- - --p----------- - - ---- ----------- ---------------------- Phone �� Address ---- - ------------------------•----------------------------- ------------------------ ---___'d---•---- 11Z Contractor's Name__. �'� ------------------ ----------- Phone- -¢�-?--�------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/___ Number of bedrooms __yam_ Number of baths - -_ Lot size ----- ---- .Z 4P Water Supply: Public system ❑ Community system ❑ Private Depth to Wafter Table °.'ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ _ Previous Application Made: Yes ❑ No W New Construction: Yex No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �6d___Distance from/ foundation- ____� �f Septic rank: Distance from nearest well________ ___ ' _ - �-----------.Maters I-------------_--------------_------------------.. 54 No. of compartments-------�_ Size--------------7-_-"Y.S Liquid depth------Y__�- Capacity---IF Disposal Field: Distance from nearest IL!__d6_,._Distance from foundation_____.. .......Distance to nearest lot line------- -°- Number of lines____________ ___------ -____________ Length of each line-------3 0�_-_ __.____.Width of trench------2-el---------------------- p� Type of filter material---$<! -------Depth of filter material---,__-.--------Total length---------�Za-_--___________-____-____. Seepage Pit: Distance to nearest well_Aa'-_.t__-_Distance from foundation----510.`---.Dunce to nearest lot line____.��0-__,__ IV Number of pits.._.___------------Lining material-- t_�-_c_____Size: Diameter__.._.______ _______Depth_____a.4,---_-_-_____..._.___� 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--------- ------------------------------------------------------------------------------------------------------------------------------ ----- Remodelingand/or repairing (describe):---------------------------------------------------------------•--------------------------------------------------------------------------- ------ ---------------------------------------------------•- -----------------------•-------------------------------------.----------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- -------------- 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 of the San Joaquin Local Health District. (Signed)---------- --------- (Owner and/or Contractor) By:. ------------------------------------ {Title}- (Plot plan, showing size of lot, locatflo of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- DATE- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------- ---------------------------------------------------- Alterationsand/or recommendations:----------------------------------------------------------------------------------------------------------- --------------------- ----------------------------- -------------------------------------I----------------------- ---------------------------------- -------------------------------------------- ------------------------------------------------------- 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—`i-2M 10-52 Revised W-2100