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# p t APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Yes�cr;bed.Date Issued _Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herei This application is made in compliance with County rdinance No. 549. ., r JOB ADDRESS AND LOCATION-- Owner's Name -�/,t�'t -------___�a____ ----- ----- -------------- Phone �� Address----------- 1 --•--•- l-------------- Contractor's Name --•• ---- --- - Phone- - Installation will serve: Residence Lr' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /--- Number of bedrooms _5; Number of baths ./-- Lot size ---- Z/------------------------- F Water Supply: Public system 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 7f Hardpan ❑ Previous Application Mader Yes ❑ No &� New Construction: Yes No F]i TYPE OF INSTALLATION AND SPECIFICATIONS: / l (No septic tank or cesspool permitted if public sewer is available within 240 feet.) ti i Septic Tank: Distance from nearest well a_�_��EDistance from fpundation-1-4---___..Materiel---!(-_-.----__-____-_--- ______________ s .� d� No. of compartments-..----._�------------Size-_�L�_yd.��- --Liquid deph-------�,�--------Capacity----- --- -__-� -• Disposal .Field: Distance from nearest well.l.y_�.1_4'-.Distance from foundation_s5P-D........Distance to nearest lot line--- ------- Number oflines---------- -- !!!4----------------------Length of each line__ _--3_P_*------Width of trench.-----,:`/.--__---------_---_-• Type or filter material-_4i--�flG,�...Depth of filter material---1�, ...........Total length--- ---------------------------- Seeps a Pit: Distance to nearest well-N01Y6----Distance from fou dation------------------.Distance to nearest lot line-----_---------- IL Number of pits....--�-------------Lining material--4R- ---- �--Size: Diameter_-__- /o"-..---..Depth----.. �___-_____..____. 'I 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):---------------- -------------------------•--------------------•------------•---------------------------------------------------------------- 1 t ------------ ------------------------- -------------------------------------I---------------•-•---•-•--•-----------•--------------------------------------------------------------------------------------------------•------------- -- 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. Si ned -- - ------------------- ------ ------------ - --------------------------------- ---------------- ---------- ---��racfor)( 9 )--------------- _ _ By -------------------- --------------(Title) ---------- (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY------------ ---------------------- ---------------------------------------- DATE----------_ d ------- REVIEWEDBY---------------------------------------------•------------- ------------------------------------------------------------------- DATE--------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------- ---------------------------------------------------- -------------- DATE----.- ------------------------------------------------------ kAlterations and/or recommendations---------------------------- ------------------------------------------------------------------------- .---------------------------- •----•-------------- --------------•------- --•---• --------------•------------------------------------------- ------------------------------• ------------------------------------------------------------------------------ ------------------------------------------------------------------- -----------•-------------------------------------------------------------------•---------------------------•-------- ---- / -------------------------------- ------------------------- FINAL INSPECTION BY:--------------------- rte/ ------ 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 0-52 Revised W-2100