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APPLICATION FOR SANITATION PERMIT Permit No.!_�_ (Complete in Duplicate) 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_________ _ ____ _ __'��_�_"`c -_- Owner's Name------------- r - " -- ; --------------------------------------------- Phone--------------------- ------ Address--------------- Contractor's - ' • _- Name--------- 'Y ------------------------ ----- Phone_--=----•---------------------- Installation will serve: Residence Z-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ .�,I Number of living units: ___f___ Number of bedrooms '9__ Number of baths _- -_ Lot size _______-____________________ Water Supply: Public system 2--community system ❑ Private ❑ Depth to Water Table ________ it. Character of soil to a depth of 3 feet: Sand.0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ V Previous Application Made: Yes E] No [:] New Construction: Yes ElNo ElTYPE .OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f a Septic T .k: Distance from nearest well_" Distance from foundation_/17------------ .Mat erial_- __________ __. _ No. of compartments------.7,---______ �{ q p ---.-._-_Capacity}__ -_Q --___ ------Size----��-`------------------Li Liquid de th----�--------- Disposal Field: Distance from nearest wefl- ---Distance from foundation-.I_..�_--------Distance to nearest line__•_-. Number of lines_________------------_---------Length of each line_ -�~ _4,247'___-.Width of trench_______ _ ____________________ Type of filter material__/X&_--�3--------Depth of filter material____I__-___________-_Total length---- d__________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------------- ❑0 Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h------_-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______________.__________--___""__. .. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. 1 Privy: Distance from nearest well------------------------------------------------- from nearest building------------------------------------------ E-1 Distance to nearest lot iine---------------------------------------------------------------------------------------------------------------------------------------------- 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, Sfafeaaws, and rules and regulations of the San Joaquin Local Health District. (Si ned 9 )----Lvne --- '-- (Owner and/or Contractor) By:-------------------------------------------------------------------------------------------------------------------------__------(Title)---------------------------------------------------------------- (Plot plan, showing size of lof, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- DATE----- ---------------------------------- DATE- BUILDING ATE_ - - BUILD NG PERMIT ISSUED---------- W------------------------------------------------------- DATE--- Alterationsand/or recommendations-------- --------------- --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------•-------—------------------------------- ------------------------------------Z------------------------------------------------------------------- J FINAL INSPECTION BY:---------------- � `- Date--- ---- -------- :'_- 4 `' ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100